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http://www.archive.org/details/obstetricspractiOOcrag 


it  IS  with  deepest  sorrow  that  we  announce 
the  death  of  Dr.  E.  B.  Cragin.  For  a  good 
many  years  Dr.  Cragin 
has  been  one  of  the 
best  known  specialists 
in  gynecology  and  ob- 
stetrics in  this  country. 
As  a  teacher  he  was 
known  and  affection- 
ately regarded  by  many 
physicians  who  have 
had  the  privilege  of 
studying  under  him.  He 
had  a  fine  scientific 
mind  and  his  contribu- 
tions to  the  branches  of 
medicine  which  engaged  his  attention  have 
been  of  a  high  order.  The  following  facts 
are  from  the  New  York  Times  (Oct.  23, 
1918)  : 
j'Dr.  Edwin  Bradford  Cragin,  prominent 
I  in  New  York  for  many  years  as  a^  ob- 
stetrician and  gynecologist,  died  on  October 
21st  of  pneumonia  at  his  home,  10  West 
Fiftieth  Street,  in  his  fifty-ninth  year.  He 
had  been  in  ill-health  for  more  than  a  year, 
but  continued  to  carry  on  his  practice  until 
a  month  ago. 

Dr.  Cragin  was  born  at  Colchester,  Conn., 
the  son  of  Edwin  Timothy  and  Ardelia 
Ellis  Cragin,  and  graduated  at  Yale  in  1882, 
got  his  M.  D.  from  the  New  York  College 
of  Physicians  and  Surgeons  in  1886,  and 
commenced  his  practice  of  medicine  in  this 
city  the  same  year,  after  serving  for  a  time 
on  the  hospital  staff  of  Roosevelt  Hospital. 
He  was  later  appointed  assistant  gynecol- 
ogist to  the  hospital  and  assistant  surgeon 
to  the  New  York  Cancer  Hospital,  and  in 
1899  became  attending  surgeon  to  the 
Sloane  Maternity  Hospital. 

Dr.  Cragin  became  prominent  as  a  gyn- 
ecologist and  obstetrician  early  in  his  career 
and  was  consulting  surgeon  to  the  City  Ma- 
ternity, Italian  and  New  York  Nursery  and 
Child's  hospitals  and  consulting  gynecol- 
ogist to  the  Presbyterian,  New  York,  Roose- 
velt, Lincoln,  St.  Luke's  and  New  York  In- 
firmary for  Women  and  Children. 

He  was  Professor  of  Obstetrics  and  Gyn- 
ecology at  the  College  of  Physicians  and 
Surgeons,  Vice-President  New  York  Acad- 
emy of  Medicine,  member  of  the  New  York 
Medical  and  Surgical  Society,  New  York 
Obstetrical  Society,  American  Gynecolog- 
ical, American  Medical  Association,  and 
many  others.  He  was  a  member  of  the  Re- 
publican, University  and  Yale  Clubs  and 
the  Board  of  Elders  of  the  Central  Pres- 
byterian Church. 

Dr.  Cragin  wrote  a  number  of  works  on 
obstetrics.  He  is  survived  by  his  wife,  a 
son,  and  two  daughters,  one  of  whom  was 


PLATE  I 


The  Vulva. 

For  key  see    Fig.    1. 


OBSTETRICS 

A  PRACTICAL  TEXT-BOOK   FOR 
STUDENTS  AND   PRACTITIONERS 


BY 

EDWIN  BRADFORD  CRAGIN,  A.B.,  A.M.  (Hon.),  M.D.,  F.A.C.S. 

PROFESSOR    OF    OBSTETRICS   AND    GYNECOLOGY,    COLLEGE    OF    PHYSICIANS    AND    SURGEONS, 
COLUMBIA    UNIVERSITY,  NEW  YORK. 

ATTENDING  OB.STETRICIAN  AND  GYNECOLOGIST  TO  THE  SLOANE  HOSPITAL  FOR  WOMEN;  CONSULTING 

OBSTETRICIAN  TO  THE  CITY  MATERNITY  HOSPITAL,  THE    ITALIAN  HOSPITAL    AND  THE  NEW 

YORK    NURSERY     AND    CHILD's    HOSPITAL;     CONSULTING    GYNECOLOGIST    TO    THE 

PRESBYTERIAN    HOSPITAL,    THE     ROOSEVELT    HOSPITAL,    THE     LINCOLN 

HOSPITAL,     THE     NEW    YORK     INFIRMARY     FOR     WOMEN     AND 

CHILDREN  AND  TO  ST.  LUKe's  HOSPITAL,  NEWBURG,  N.  Y. 

ASSISTED   BY 

GEORGE  H.  RYDER,  A.B.,  M.D. 

INSTRUCTOR  IN  GYNECOLOGY,  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  COLUMBIA  UNIVERSITY, 

NEW    YORK;    ASSISTANT    ATTENDING    OB.STETRICIAN,  SLOANE    HOSPITAL    FOR 

women;     ASSOCIATE     SURGEON,    WOMAN* S    HOSPITAL. 


ILLUSTRATED   WITH    499    ENGRAVINGS  AND    13    PLATES 


LEA   &   FEBIGER 

PHILADELPHIA  AND  NEW  YORK 


Entered  according  to  the  Act  of  Congress,  in  the  year  1916,  by 

LEA  &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


TO   THE    MEMORY 

OF 

DR.  JAMES   W.  McLANE, 

HIS  OLD  TEACHER  AXD   FRIEXD,   AND  THE  FIRST  ATTENDING  PHYSICIAN 

TO 

THE    SLOANE    MATERNITY    HOSPITAL, 

THIS  BOOK  IS  RESPECTFULLY  DEDICATED 

BY  THE  AUTHOR. 


PREFACE. 


During  a  protracted  service  as  medical  head  of  the  Sloane  Hospital 
for  Women,  where  over  eighteen  hundred  deliveries  annually  occur, 
the  author  has  enjoj^ed  exceptional  opportunities  for_observation  and 
experience  in  obstetrics;  and  for  several  years  he  has  felt  the  growing 
sense  of  a  duty  to  place  before  the  profession  and  students  of  medicine 
the  methods  of  this  institution  and  the  results  obtained.  The  present 
Text-book  of  Obstetrics  has  seemed  to  him  the  most  rational  and  perhaps 
the  most  useful  way  in  which  to  meet  this  obligation.  It  will  hardly  be 
necessary  to  point  out  to  the  reader  that  the  work,  in  the  methods  advo- 
cated, is  based  upon  the  statistical  results  of  the  Sloane  Hospital  and 
upon  the  experience  gained  by  the  author  in  the  hospital  and  in  private 
practice.  Another  object  of  the  work  has  been  to  present  American 
statistics  in  obstetrics. 

The  fact  that  many  of  the  text-books  now  before  the  profession, 
although  very  valuable  for  reference,  are  too  large  for  the  undergraduate 
student,  has  long  been  appreciated  by  the  author;  hence  in  the  following 
pages  he  has  endeavored  to  cover  the  subject  concisely  and  to  eliminate 
unnecessary  discussion.  With  this  in  view  he  has  made  no  effort  to 
present  a  complete  bibliography  of  the  subject,  although  references  to 
important  articles  on  most  subjects  are  given. 

It  will  be  noticed  that  the  subjects  of  pelvimetry  and  the  antepartum 
examination  are  included  in  Chapter  Y  under  the  Management  of  Normal 
Pregnancy.  The  author  maintains  that  for  the  proper  management 
of  a  pregnancy  the  obstetrician  should  inform  himself  at  the  earliest 
opportunity  as  to  both  the  exact  size  and  shape  of  the  pelvic  canal, 
and  should  ascertain  the  presentation  of  the  fetus. 

Opinions  will  probably  differ  as  to  the  wisdom  of  placing  Chapter  VI, 
Multiple  Pregnancy,  in  Part  II  under  Physiological  Pregnancy.  The 
author's  reason  for  doing  so  is  that  in  the  majority  of  instances  multiple 
pregnancy  is  physiological  and  the  labor  not  abnormal.  The  troublesome 
question  is  the  location  of  complicated  labor  in  multiple  pregnancy.  It 
more  logically  belongs  in  Part  V  under  Pathological  Labor,  but  this 
arrangement  would  involve  a  division  of  the  subject  of  multiple  pregnancy 


VI  PREFACE 

and  a  separation  of  the  parts  by  many  intervenins;  chapters,  Mhich 
seemed  to  the  anthor  nnwise.  He  has  therefore  completed  the  sul)ject 
in  one  chapter  even  if  in  discussing  the  management  of  compHcated 
hxbor  in  multiple  i)regnancy  he  has  anticipated  methods  of  treatment. 

For  great  assistance  in  preparation  of  the  part  of  the  work  treating 
of  embryology  the  author  is  pleased  to  acknowledge  his  obligation  to 
Adam  M.  Miller,  Ph.D.,  professor  of  anatomy  at  The  Long  Island  College 
Hospital. 

In  the  matter  of  illustrations,  both  drawings  and  ])hotographs,  the 
author  wishes  to  express  to  ]Mr.  K.  K.  Bosse,  of  New  York,  appreciation 
of  his  painstaking  work. 

E.  B.  C. 

New  York,  19  1G. 


CONTENTS. 


PART  I. 
ANATOMY  AND  EMBRYOLOGY. 

CHAPTER   I. 

Anatomy  of  the  Female  Generative  Organs 17 

CHAPTER   II. 

Embryology  and  Physiology 54 


PART  II. 
PHYSIOLOGICAL  PREGNANCY  AND  ITS  MANAGEMENT. 

CHAPTER   III. 

Changes  Produced  in  the  Maternal  Organism 123 

CHAPTER   IV. 

The  Symptoms  and  Signs     of     Pregnancy.       Their     Relative  Value  in 

Diagnosis 140 

CHAPTER   V. 

The  Management  of  Normal  Pregnancy 149 

CHAPTER  VI. 
Multiple  Pregnancy 191 

0                                          CHAPTER  VII. 
Normal  Labor ~ 204 

(V) 


viii  CONTENTS 

CHAPTER  VIII. 

The  Mechanism  of  Labor 2H) 

CHAPTER  IX. 

The  Management  of  Normal  Labor /    307 

CHAPTER  X. 

Care  of  Child  in  Abnormal  Condition  at  Birth 351 

CHAPTER  XL 
The  Puerperitjm  and  its  Management 369 


PART  III. 
PATHOLOGICAL  PREGNANCY. 

CHAPTER  XII. 
Toxemia  of  Pregnancy 417 

CHAPTER  XIII. 
Local  and  General  Affections  and  Diseases  Complicating  Pregnancy      444 

CHAPTER  XIV. 

Diseases  of  the  Fetal  Membranes 491 

CHAPTER  XV. 

Abortion 506 

CHAPTER  XVI. 

Ectopic  Gestation.     Pregnancy  in  Malformed  Uteri 522 

CHAPTER  XVII. 
Hemorrhage 564 

CHAPTER   XVIII. 
Pyelitis  Complicating  Pregnancy 596 


CONTENTS  IX 

PART  IV. 
PATHOLOGICAL  LABOR. 

CHAPTER  XIX. 
Abnormal  Labor  from  Anomalies  in  Forces 609 

CHAPTER  XX. 

Abnormal  Labor  from  Anom.u^ies  in  the  Passages 624 

CHAPTER  XXI. 
Abnormal  Labor  from  Anomalies  op  the  Fetus  ant)  in  Presentation         697 

CHAPTER  XXII. 

Prolapse  of  the  Cord 718 


PART  V. 

OBSTETRIC  SURGERY. 

CHAPTER  XXIII. 

Injuries  to  the  Parturient  Canal -723 

CHAPTER   XXIV. 
Induction  of  Abortion  and  Premature  Labor 732 

CHAPTER  XXV. 

Forceps  ' '*^ 


CHAPTER  XXVI. 


Version 


768 


CHAPTER  XXVII. 
Delivery  by  Methods  Distinctly  Surgical 776 


X  CONTENTS 

PART  VI. 

PATHOLOGICAL  PUERPERIUM. 

CHAPTER   XXVIII. 
Puerperal  Infection 809 

CHAPTER  XXIX. 

Infant  Mortality  836 

Index  841 


OBSTETRICS. 


PART  I. 
ANATOMY  AND  EMBEYOLOGY. 


CHAPTER  I. 

ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS. 

The  art  of  obstetrics  comprises  the  study  and  care  of  the  woman  and 
the  product  of  her  conception  from  the  time  of  her  impregnation  until 
subsequent  to  her  deUvery  she  is  able  to  resume  her  usual  occupation. 
A  thorough  knowledge  of  the  factors  involved  in  this  process  of  repro- 


iVICULARIS 


Fig.  1. — The  vulva. 

duction  demands  a  careful  study  of  the  female  generative  organs  and 
those  neighboring  organs  which,  although  not  distinctively  "  generative/' 
are  intimately  associated  with  the  process. 

For  purposes  of  description  the  female  generative  organs  are  divided 
into  the  external  and  the  internal. 

2  (17) 


18 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 


THE   EXTERNAL   ORGANS    OF    GENERATION. 

The  external  organs  of  generation,  grouped  under  the  common  term 
of  the  ndva,  or  imdendum,  inchide  the  mons  veneris,  the  labia  majora, 
the  labia  minora,  the  clitoris,  the  vestibule  with  the  urethral  orifice,  the 
hymen  and  certain  erectile  and  glandular  structures. 

It  will  be  seen  from  Plate  I  and  Fig.  1  that  the  vulva  is  bounded  in  front 
by  the  anterior  abdominal  wall,  behind  by  the  perineum,  and  laterally 
bv  the  inner  surface  of  the  thighs.' 


r^ 


FOUI^CHETTL 


FOSSA  NAVICULARS 


Fig.  2. — Nulliparous  woman,  labia  separated. 

Mons  Veneris. — The  mons  veneris  is  a  cushion  of  areolar  and  adipose 
tissue  situated  in  front  of  the  upper  part  of  the  symphysis  pubis.  It  is 
covered  with  skin,  which  after  puberty  becomes  pigmented  and  thickly 
set  with  hair. 

Labia  Majora. — The  labia  majora  are  two  folds  of  modified  integument 
bordering  the  cleft  of  the  vulva.  They  are  continuous  with  the  mons 
veneris  in  front,  where,  by  their  junction,  they  form  the  anterior  com- 
missure; posteriorly  they  extend  to  within  an  inch  of  the  anus,  and  there 
becoming  very  thin,  unite  in  the  posterior  commissure,  or  fovrchette, 
which  forms  the  anterior  edge  of  the  perineum. 

When  the  labia  majora  are  separated  in  the  \'irgin  or  nulliparous 
woman  (Plate  II  and  Fig.  2)  there  is  found  between  the  fourchette  and  the 
hymen  a  depression  called  the  fossa  navicularis.    After  puberty  the  outer 


1  In  the  illustrations  and  description  of  the  external  generative  organs  the  woman  is  sup- 
posed to  be  in  the  lithotomy  position,  i.  e.,  on  the  back,  with  thighs  flexed  and  separated. 


PLATE  II 


Nulliparous  Woman.    Labia  Separated. 

For  kev  see   Fiq    2. 


THE  EXTERNAL  ORGANS  OF  GENERATION  19 

surface  of  the  labia  majora  is  deeply  pigmented,  covered  with  hair, 
and  abundantly  supplied  with  sebaceous  and  sudoriparous  glands.  The 
inner  surface  is  also  covered  with  skin,  near  the  free  border  resem- 
bling that  on  the  outer  surface,  but  deeper  in,  more  delicate,  moist,  and 
resembling  mucous  membrane.  Rudimentary  hairs  are  visible  on  close 
inspection  and  there  are  numerous  sebaceous  glands.  In  well-nourished 
virgins  the  labia  majora  are  usually  closely  approximated  and  conceal 
the  parts  within.  In  the  aged,  emaciated  and  those  who  have  borne 
many  children,  the  labia  majora  usually  gape. 

Beneath  the  skin  of  each  labium  majus  there  is  found  a  tissue  resem- 
bling the  dartos  of  the  scrotum  but  thinner;  beneath  this  are  layers 
of  adipose,  connective,  and  elastic  tissue.  At  the  upper  part  of  each 
labium  there  may  sometimes  be  found  the  remains  of  the  canal  of  Nuck. 
The  labia  majora  correspond  morphologically  to  the  scrotum  in  the 
male. 

The  Labia  Minora  or  Nymphae. — The  labia  minora  or  nymphse  are 
two  smaller  folds  of  modified  skin  lying  within  the  labia  majora  and 
extending  from  the  clitoris  in  front  downward  and  backward  to  merge 
into  the  labia  majora,  usually  about  their  middle  or  lower  third.  In  some 
women  they  seem  to  join  each  other  in  the  posterior  commissure.  The 
labia  minora  are  triangular  in  shape  with  bases  upward.  At  the  clitoris 
the  base  of  each  divides  into  two  portions,  the  upper  uniting  with  its 
fellow  of  the  opposite  side  above  the  dorsum  of  the  clitoris  to  form  its 
prepuce;  the  lower  uniting  w^ith  its  fellow  just  beneath  the  clitoris  to 
form  its  frsenum.  The  labia  minora  vary  greatly  in  shape  and  size;  they 
are  sometimes  asymmetrical  and  sometimes,  as  in  the  Hottentot  M^oman, 
greatly  hypertrophied.  They  are  directly  continuous  externall}^  with 
the  labia  majora  and  internally  with  the  mucous  membrane  of  the 
vestibule.  In  the  virgin  they  are  usually  concealed  by  the  labia  majora; 
their  skin  is  then  delicate  and  moist  and  greatly  resembles  mucous 
membrane. 

When,  however,  as  a  result  of  child-bearing  or  frequent  coitus  they 
project  beyond  the  labia  majora,  they  lose  more  or  less  of  this  character 
and  become  dry  and  pigmented.  Their  surfaces  are  free  from  hairs  and 
sudoriparous  glands  but  are  richly  supplied  with  sebaceous  glands  and 
with  sensitive  papilla?.  Beneath  the  surface  of  the  labia  minora  is  a 
vascular  connective  tissue  rich  in  elastic  and  smooth  muscle  fibers  but 
containing  no  fat. 

The  Clitoris. — The  clitoris,  the  homologue  of  the  penis  in  the  male  is 
a  small  erectile  organ  about  an  inch  long  situated  between  the  anterior 
extremities  of  the  labia  majora  at  the  forepart  of  the  vestibule.  Like 
the  penis  it  consists  of  a  glans,  a  body  and  two  crura;  it  has  a  prepuce 
and  a  frsenum  both  derived  from  the  labia  minora,  and  is  also  provided 
with  a  suspensory  ligament. 

The  clitoris  differs  structurally  from  the  penis  in  possessing  no  corpus 
spongiosum  and  no  urethra,  the  latter  being  situated  just  above  the 
anterior  wall  of  the  vagina  with  its  meatus  in  the  base  of  the  anterior 
triangular  portion  of  the  vestibule. 


20  ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 

The  Glans. — The  glans,  visible  when  the  labia  minora  are  separated,  is  a 
mass  of  erectile  tissue  about  the  size  of  a  small  pea  and  is  highly  sensitive, 
being  richly  supplied  with  nerves  ending  in  the  so-called  genital  corpuscles. 

The  glans  is  surrounded  at  its  base  by  sebaceous  glands  secreting  a 
smegma  which  may  be  retained  by  preputial  adhesions  and  give  rise  to 
irritation. 

The  Body. — The  body  of  the  clitoris  is  composed  of  two  corpora  cavernosa, 
similar  in  minute  structure  to  those  of  the  male,  and  separated  by  an 
imperfect  septum. 

The  Crura. — The  crura  are  the  prolongations  of  the  corpora  cavernosa 
which  diverge  posteriorly  to  be  attached  to  the  ischiopubic  rami  super- 
ficial to  the  triangular  ligament.  They  are  covered  by  the  ischio- 
cavernosi  (erectores  clitoridis)  muscles. 

The  Vestibule  (see  Fig.  1). — The  vestibule,  best  understood  as  the 
remains  of  the  urogenital  sinus,  is  the  space  lying  between  the  labia 
minora  and  the  hymen.  It  is  bounded  in  front  by  the  clitoris,  behind 
by  the  fourchette,  laterally  by  the  labia  minora.  Opening  into  it  are 
the  urethra  and  the  ducts  of  the  vulvovaginal  glands.  The  anterior 
portion  of  the  vestibule  is  triangular  in  shape  and  by  some  authors  the 
term  vestibule  is  restricted  to  this  triangular  area.  The  meatus  urinarius 
lies  in  the  base  of  this  triangular  portion,  the  mucous  membrane  sur- 
rounding it  being  usually  elevated  and  corrugated  from  the  encircling 
non-striated  muscular  fibers.  Near  the  meatus  are  often  seen  the 
openings  of  several  large  mucous  crypts. 

The  Hymen. — The  hymen  is  a  thin  fold  of  mucous  membrane  arising 
from  a  reduplication  of  the  lowermost  part  of  the  vaginal  walls  and 
closing  to  a  greater  or  less  degree  the  vaginal  orifice.  In  structure  it  is 
composed  of  a  connective-tissue  framework  rich  in  elastic  fibers  and 
supplied  with  bloodvessels  and  nerves;  it  is  covered  on  both  sides  with 
mucous  membrane.  The  hymen  varies  greatly  in  shape  and  extent  in 
different  individuals,  as  seen  in  Figs.  3  to  10.  The  most  usual  shape  is  the 
crescentic  (see  Fig.  3),  occluding  the  posterior  portion  of  the  vaginal  orifice, 
the  concavity  looking  forward  toward  the  pubes.  Other  forms  are  the 
anmdar,  forming  a  ring  about  the  opening;  the  fimbriated  or  fringed;  the 
bilabial  with  a  central  longitudinal  cleft;  the  septate  with  two  openings 
divided  by  a  septum;  the  cribriform  with  numerous  small  openings;  and 
rarely  the  hymen  completely  occludes  the  vagina,  forming  the  imper- 
forate variety.  The  hymen  is  usually,  though  not  always,  torn  during  the 
first  sexual  intercourse;  it  is  also  often  torn  in  a  gynecological  examina- 
tion. Its  presence  intact  is  therefore  not  a  certain  proof  of  chastity 
nor  its  rupture  a  sure  evidence  of  intercourse.  After  parturition  there 
remains  of  the  hymen  only  fleshy  tags  attached  around  the  vaginal 
orifice;  these  are  called  the  carunciilce  myrtiformes  (see  Fig.  10). 

The  bulbs  of  the  vestibule  {bidbi  vestibidi)  (see  Plates  III  and  IV) 
are  two  leech-shaped  venous  plexuses  about  ap  inch  in  length  lyin^  on 
either  side  of  the  vestibule  underneath  the  labia  minora;  they  may  be 
regarded  as  the  cleft  homologue  of  the  corpus  spongiosum  in  the  male. 
These  venus  plexuses,  enclosed  within  a  thin  fibrous  capsule,  are  rounded 


THE  EXTERNAL  ORGANS  OF  GENERATION 


21 


posteriorly  but  taper  anteriorly  and  are  continued  forward  on  each  side 
by  means  of  a  venous  plexus,  the  j)<^>'s  intermedia,, which  communicates 
with  its  fellow  beneath  the  clitoris.    There  is  here  free  communication 


Fig.  3. — The  crescentic. 


Fig.  4. — The  annular. 


Fig.  5. — The  fimbriated. 


Fig.  6.— The  bilabial. 


between  the  bulbs  of  the  vestibule,  the  veins  of  the  labia  majora  and 
minora,  and  the  veins  of  the  clitoris.  The  bulbs  of  the  vestibule  are 
overlapped  by  the  bulbocavernosi  {constrictores  vagince)  muscles  and  by 


00 


AX  ATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


their  contractions  during  sexual  excitement  the  hulhs  become  turgid 
and  erect,  tlnis  narrowing  the  vaginal  orifice. 

The  vulvovaginal  glands,  or  glands  of   Bartholin,  are  two  racemose 
glands,  round  or  o\"al  in  outline,  lying  on  either  side  of  the  vaginal  orifice 


Fig.  7. — The  septate. 


Fig.  S. — The  cribriform. 


Fig.  9. — T;.>.  ::;.,,■.: lurate. 


Fig.   10.— ( 


mvrtiformes. 


usually  superficial  to  the  triangular  ligament.  They  are  overlapped  by  the 
lower  extremities  of  the  bulbs  of  the  vestibule.  (See  Plate  III.)  They 
measure  about  a  third  of  an  inch  in  diameter  and  their  ducts,  each  about 


PLATE  III 


FIC.    1 


The  Bulbs  of  the  Vestibule.     (Playfair.) 

a,  bulb  of  vestibule;  6,  muscular  tissue  of  vagina;  c,d,e,f,  the  clitoris  and 
muscles;  g,  h,  i,  k,  I,  m,  n,  veins  of  the  nymphas  and.  clitoris  communicating 
with  the  epigastric  and  obturator  veins. 

FIG.  2 


The  Clitoris.     (After  Kobelt.) 

A,  bulbus  vestibuli ;  C,  pars  internmedia  ;  E,  glans  clitoridis  ;  F,  corpus  clitoridis  ; 
H,  dorsal  vein;    L,  right  crus  ;    M,  vestibule;    N,  gland  of  Bartholin. 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 


23 


half  an  inch  in  length,  open  just  in  front  of  the  hymen  on  each  side.    They 
are  homologues  of  Cowper's  glands  in  the  male  and  secrete  a  glairy  mucus. 


Plane  of  median  sagittal  section 


Plane  of  lateral  sagittal  section 


Fig.   11. — Anterior  view  of  cadaver  indicating  lines  of  median  section  shown  in  Figs.  13  and 
14  and  of  lateral  section  shown  in  Figs.  15,  16,  and  17. 


Plane  of  lateral  sagittal  section         Plane  of  median  sagittal  section 


Fig    12  —Superior  view  of  cadaver,  showing  planes  of  lateral  sagittal  section  (Figs    15,  IG^ 
and  17),  median  sagittal  section  (Figs.  13  and  14),  and  coronal  section  (Fig.  21). 

The  vagina,  internal  generative  organs  and  pelvic  floor  will  be  best 
understood  by  a  careful  study  of  the  accompanying  illustrations.  Figs. 


24 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 


11   to   17  jiiid   21,  from  frozen   sections  made  for  the  author  by   J)r, 
Frederick  T.  Van  Beuren,  Jr.,  of  New  York. 

The  Vagina  (see  Fig.  13).— The  vagina  is  the  canal  connecting  the 
external  organs  of  generation  with  the  uterus,  the  canal  through  which 
sexual  intercourse  takes  place  and  along  which  the  child  passes  from 
the  uterus  to  the  outside  world.  It  is  a  musculomembranous  canal 
lying  in  the  median  line  of  the  pelvis  between  the  bladder  and  urethra 
in  front  and  the  rectum  behind;  it  being  separated  from  the  latter  below 
by  the  pyramidal  bod>-  called  the  perineum.     The  vagina  is  smaller 


Body  of 
5th  L.  V. 


Peritoneum 

Prevesical 

space 
Svniphj'sis 

"pubis 
Bladder 

mucosa 
Mods  veneris 

Urethra 

Vaginal 

mucosa 
Clitoris 


Labium  minus 
Fourchette 


Fig.   13. — Median  sagittal  section. 


below,  expanded  above  into  the  fornix  or  vault  which  receives  the  cervix. 
With  the  exception  of  the  upper  expanded  portion  of  the  vaginal  canal 
it  is  normally  found  collapsed  anteroposteriorly ;  the  anterior  and  posterior 
walls  lying  in  contact  in  the  median  line,  slightly  expanded  laterally, 
giving  on  transverse  section  the  shape  seen  in  Fig,  18,  sometimes 
resembling  the  letter  H.  The  axis  of  the  canal  is  somewhat  sigmoid  in 
shape  corresponding  with  the  forward  curve  of  the  rectum,  but  in  general 
it  conforms  to  the  axis  of  the  pelvic  canal.  The  anterior  vaginal  wall  is 
shorter  than  the  posterior;  the  cervix,  as  it  were,  being  set  into  the  anterior 
wall  and  shortening  it  to  this  extent. 


THE  VAGINA 


25 


The  anterior  wall  measures  about  6.5  cm.  (2|  in.)  the  posterior  wall 
9  cm.  (3|  in.).  For  convenience  in  describing  organs  or  conditions  felt 
through  the  upper  expanded  portion  of  the  vagina,  the  fornix  or  vault 
is  often  subdivided  into  the  anterior,  posterior,  and  lateral  fornices. 

In  structure  the  vaginal  wall  consists  of  three  coats:  (1)  an  outer, 
connective-tissue  coat  derived  from  the  rectovesical  fascia;  (2)  a  middle, 
muscular  coat  of  unstriped  muscular  fibers  in  two  layers,  an  outer, 
longitudinal  and  an  inner,  circular  layer;  and  (3)  an  internal  coat  of  mucous 


Rectum 


Coccyx 


Posterior  fornix 
Anterior  fornix 


Recto-uterine  pouch  - 


Ixternal  sphincter  ani 
Ampulla  of  rectum 

Anal  orifice 


T^^W- 


^         '      '  '. 

External  sphincter  ani     Peri-    Vaginal  muscularis 
neal 
body 

Fig.   14. — Median  sagittal  section. 


membrane.  The  mucous  membrane  is  covered  with  stratified  squamous 
epithelium  continuous  with  the  epithelium  covering  the  vaginal  portion 
of  the  cervix  above  and  the  hymen  below.  The  mucous  membrane  is 
thrown  into  two  median  longitudinal  ridges  called  the  columns  of  the 
vagina,  situated  one  on  the  anterior,  the  other  on  the  posterior  wall. 
From  these  extend  transversely  numerous  folds,  or  rug(B.  All  of  these 
vaginal  markings  are  more  distinct  below  than  above,  and  most  distinct 
on  the  anterior  vaginal  wall  in  a  virgin.  With  the  exception  of  a  few 
tubular  follicles  in  the  upper  part  of  the  canal  the  vagina  normally  has 


26 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 


no  glands.     The  acid  reaction  of  the  \aginal  secretion  is  at  present 
assigned  to  the  action  of  several  microorganisms. 

The  rekdiun.s  of  the  vagina  are  as  follows:  The  upper  half  of  the  anterior 
wall  lies  in  relation  with  the  bladder,  the  lower  half  with  the  urethra. 
The  bladder  and  upper  third  of  the  urethra  are  separated  from  the 
vaginal  wall  by  areolar  connective  tissue;  the  lower  two-thirds  of  the 
urethra  lie  imbedded  within  the  anterior  vaginal  wall.  The  posterior 
vaginal  wall  is  covered  above,  for  about  an  inch,  by  peritoneum  as  it 
descends  from  the  uterus  to  form  the  pouch  of  Douglas;  its  middle  portion 


Peritoneum 
Transversalis  fascia 

Pelvic  fascia 
"White  line"- 
Reetovesical  fascia 
Obturator  facia  . 
Levator  ani  muscle 
Anal  fascia 
Deep  layer  triang.  lig. . 
Intraligamentous  space 
Superficial  layer  of 
triangular  ligament 


Fig.  15. — Lateral  sagittal  section. 


lies  in  relation  with  the  rectum,  its  lower  portion  diverges  from  the  rectum 
from  which  it  is  separated  by  the  perineal  body.  The  lateral  fornices 
of  the  vagina  lie  in  relation  with  the  bases  of  the  broad  ligaments  which 
extend  from  the  sides  of  the  uterus  to  the  lateral  walls  of  the  pelvis. 

The  bladder  and  urethra  bear  such  intimate  relations  to  the  uterus, 
vagina  and  the  practice  of  obstetrics  that  they  will  be  briefly  described 
here. 

The  Bladder. — The  bladder  when  empty  lies  within  the  true  pelvis 
between  the  symphysis  pubis  in  front  and  the  uterus  and  vagina  behind 
(see  Fig.  13).     The  summit  in  this  condition  is  flattened  or  depressed 


THE  BLADDER  AND   URETHRA 


27 


so  that  the  cavity  of  bladder  and  urethra  together  appear  Y-shaped 
on  sagittal  section.  The  summit  of  the  bladder  is  covered  by  peritoneum 
which  is  reflected  thence  forward  to  line  the  anterior  abdominal  wall; 
backward  to  cover  the  uterus.  The  bladder  has  a  muscular  wall  lined 
with  mucous  membrane.  The  muscular  structure  consists  of  two  coats, 
the  outer  being  circular,  the  inner  longitudinal,  which  are  continued 
downward  over  the  urethra.  The  mucous  membrane  is  covered  with 
stratified  transitional  epithelium.  The  bladder  when  distended  rises 
into  the  abdomen  above  the  pubes  and  tends  to  displace  the  uterus 
backward. 


1st  sacral 
vertebra 


Pyriformis 
-  Peritoneum 

Rectum 


Coccygeus 


Levator  ani 
Fig.  16. — Lateral  sagittal  section. 

The  Urethra.— The  urethra,  a  canal  about  4  cm.  (1|  in.)  in  length 
and  5  mm.  in  diameter,  extends  from  the  neck  of  the  bladder  downward 
and  forward  to  the  meatus  urinarius  in  the  base  of  the  triangular  portion 
of  the  vestibule.  Its  muscular  coat,  consisting  of  an  outer  circular  and 
an  inner  longitudinal  layer,  corresponds  to,  and  is  continuous  with,  the 
muscular  coat  of  the  bladder.  The  mucous  membrane  is  thrown  into 
longitudinal  folds  by  the  elastic  fibers  which  are  numerous  in  the 
submucous  layer;  it' is  covered  with  stratified  transitional  epithelium 
continuous  with  that  of  the  bladder. 


28 


ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


Numerous  tubular  glands  are  present  and  in  the  Hour  of  the  urethra 
near  the  meatus  are  two  tubules  of  larger  size  known  as  Skene's  glands. 

x\round  the  meatus  urinarius  the  mueous  membrane  is  often  thrown 
into  folds  of  various  shapes,  sometimes  called  urethral  labia. 

The  Rectum. — The  only  jjortion  of  the  rectum  which  especially  con- 
cerns the  obstetrician  is  that  part  which  perforates  the  pelvic  floor  and 
is  uncovered  by  peritoneum.  Beginning  at  the  point  where  the  peri- 
toneum is  reflected  from  the  anterior  surface  of  the  rectum  on  to  the  vault 
of  the  vagina,  forming  the  pouch  of  Douglas  or  recto-uterine  pouch  (see 


Uterus 
Fallopian  tube 
Body  of  pubis 
Bladder 
Broad  ligament 
Obturator  ext. 
Obturator  int. 

Glass  rod  above 
superior  layer 
triangular  lig. 
Crus  clitoridis 

Glass  rod  below 
inferior  layer 
triangular  lig. 


Intraligamentous  space 
Fig.  17. — Lateral  sagittal  section. 


Fig.  19),  the  rectum  runs  for  a  short  distance  parallel  to  the  posterior 
wall  of  the  vagina  and  is  adherent  to  it.  At  about  4  cm.  (1|  in.)  above 
its  lower  extremity  it  curves  backward  away  from  the  vagina  to  terminate 
in  its  external  opening,  the  anus. 

The  space  thus  formed  by  the  divergence  of  the  lower  ends  of  the 
rectum  and  vagina  is  occupied  by  the  pyramidal  mass  of  muscular, 
fibrous  and  adipose  tissue  called  the  perineal  body.  Below  the  point 
of  reflection  of  the  peritoneum  from  the  rectal  wall  the  coats  of  the 
rectum  are  muscular  and  mucous,  united  by  submucous  tissue.     The 


THE  RECTUM 


29 


muscular  coat  is  composed  of  two  layers,  an  external  longitudinal  and 
an  internal  circular. 

The  lower  extremity  of  the  rectum  is  guarded  by  two  constricting 
bands  of  muscle;  the  external  and  internal  sphincters.  The  former  is 
composed  of  voluntary  muscle  fibers,  while  the  latter  consists  of  an 
aggregation  of  the  involuntary  circular  fibers  of  the  rectal  wall. 

The  External  Sphincter. — ^The  external  sphincter  arises  from  the  pos- 
terior surface  of  the  coccyx  and  from  the  fibrous  layer  of  the  skin  over 
it  and  passes  forward  to  surround  the  anus.  It  is  composed  of  two 
layers,  the  superficial  and  deep. 

The  deep  layer  of  the  external  sphincter  is  circular  and  entirely  sur- 
rounds the  anus.    The  fibers  of  the  superficial  layer  at  first  run  parallel, 
then  separate  to  surround  the  anal  portion  of  the  rectum,  then  reunite 
to  be  inserted  into  the  tendinous  centre 
of  the  perineum,  some  of  the  fibers  being 
continuous  in  front  with  the  fibers  of  the 
bulbocavernosi      (constrictores     vaginae) 
muscles  (see  Fig.  23). 

The  external  sphincter  is  intimately 
adherent  to  the  integument  surrounding 
the  anus;  this  integument  being  pig- 
mented and  throwm  into  radiating  folds. 

The  Internal  Sphincter. — The  internal 
sphincter,  composed  of  an  aggregation  of 
the  circular  fibers  of  the  rectal  wall,  begins 
about  4  cm.  (1|  in.)  above  the  anal  margin 
and  increases  in  thickness  as  it  descends 
until  it  reaches  the  anorectal  line,  then 
thins  out  again.  Its  lower  fibers  lie  be- 
low and  within  the  grasp  of  the  external 
sphincter  but  are  separated  from  it  by  a 
narrow  zone  of  connective  tissue.  The 
mucous  membrane  of  the  lower  end  of  the 
rectum  is  thrown,  especially  during  con- 
traction of  the  sphincter,  into  longitudinal  folds  called  the  columns  of 
Morgagni  or  columns  of  the  rectum.  The  grooves  between  these 
columns  deepen  from  above  downward  and  end  in  the  semilunar 
valves  or  crypts  of  Morgagni. 

The  rectal  mucous  membrane  above  the  crypts  of  Morgagni  is  thrown 
into  irregular  horizontal  folds  most  of  which  disappear  when  the  rectum 
is  distended  but  at  three  or  four  points  they  usually  remain  permanent 
and  are  called  the  valves  of  Houston  or  the  rectal  valves.  These  valves 
vary  in  number  from  three  to  five.  Usually  there  are  three,  called  the 
superior,  middle  and  inferior  rectal  valves  (see  Fig.  19).  The  middle 
valve  is  the  most  constant  and  arises  from  the  right  anterior  quadrant 
of  the  rectal  wall  about  6  to  9  cm.  (2f  to  3|  in.)  above  the  anal  margin. 
The  superior  valve  arises  from  the  left  posterior  quadrant  9  to  11  cm. 
(4|  to  5|  in.)  above  the  anus  and  the  inferior  valve  lies  in  about  the 


Fig.  18. — Transverse  section  of 
the  lower  portion  of  the  vagina. 
(Henle.)  L,  levator  ani  muscle;  R, 
rectum;  U,  urethra;  V,  vagina. 


30 


ANATOMY  OF   THE  FEMALE  GENEHATIVE  ORGANS 


same  quadrant,  25  to  30  millimeters  (1  to  li  in.)  above  the  anal 
margin. 

Lining  the  bony  framework  of  the  true  pelvis  and  largely  closing  the 
openings  in  its  wall  are  two  muscles  on  each  side,  the  obturator  intcrnus 
and  the  yyriformis. 

The  Obturator  Intemus. — The  obturator  internus  muscle  on  each 
side  of  the  pelvis  arises  from  the  bony  surface  between  the  obturator 
foramen  in  front,  the  great  sacrosciatic  notch  behind,  and  the  iliopec- 
tineal  line  above.     It  also  arises  from  the  inner  surface  of  the  obturator 


Fig.   I'J. — The  rectum  luid  its  relations. 


membrane,  except  a  little  of  its  lower  part,  and  from  the  tendinous  arch, 
completing  the  canal  for  the  passage  of  the  obturator  vessels  and  nerve. 
It  is  inserted  into  the  upper  border  of  the  great  trochanter.  The  obturator 
internus  muscle  thus  lines  and  cushions  the  greater  part  of  the  anterior 
and  lateral  wall  of  the  pelvis  on  each  side.  The  inner  surface  of  this 
muscle  is  covered  by  the  obturator  fascia. 

The  Pyriformis  Muscle. — The  pyriformis  muscle  arises  from  the 
anterior  surface  of  the  second,  third  and  fourth  sacral  segments,  between 
and  external  to  the  anterior  foramina;  from  the  margin  of  the  great 
sacrosciatic  foramen  and  from  the  anterior  surface  of  the  great  .'  xtq- 


PELVIC  FLOOR 


31 


sciatic  ligament.  It  is  inserted  into  the  upper  border  of  tlie  great  tro- 
chanter, its  tendon  usually  blending  with  that  of  the  obturator  internus. 
The  pyriformis  muscle  thus  helps  to  form  and  cushion  the  posterior  and 
posterolateral  wall  of  the  true  pelvis. 

The  nerve  supply  of  the  obturator  internus  and  pyriformis  muscle  is 
from  the  sacral  plexus. 

Pelvic  Floor. — Before  describing  the  internal  organs  of  generation 
it  is  fitting  that  the  pelvic  floor,  above  which  they  are  placed  and  from 
which  they  gain  support  should  be  studied.  This  pelvic  floor,  which  is 
bounded  externally  by  skin  and  internally  by  peritoneum,  closes  the 
irregularly  shaped  opening  at  the  bottom  of  the  pelvis.  Composed  chiefly 
of  muscle,  the  different  fascise  and  connective  tissue,  it  is  perforated  by 
the  rectum  and  vagina  and  in  the  anterior  wall  of  the  latter  canal  is 


Fig.  20. — The  pelvic  floor,  seen  from  above. 

located  the  lower  end  of  the  urethra.  Mewed  in  a  median  sagittal 
section  (see  Fig.  13),  the  pelvic  floor  is  seen  to  be  divided  by  the  vagina 
into  two  portions,  an  anterior  and  a  posterior,  called  respectively  by 
Hart  the  pubic  segment  and  the  sacral  segment. 

During  labor  the  pubic  segment  is  drawn  upward;  the  sacral  segment 
is  forced  downward. 

Stretching  across  the  outlet  of  the  pelvis  and  with  the  fascia?  above  and 
below  forming  the  chief  part  of  the  pelvic  floor  are  two  muscles  on  each 
side,  the  levator  ani  and  the  coccygeus. 

The  Levator  Ani  (see  Fig.  20).— The  levator  ani,  the  most  important 
muscle  of  the  pelvic  floor,  consists  of  two  portions,  namely  the  pubo- 
coccygeus  and  ischiococcygeus;  the  former  arises  from  the  posterior 
aspect  of  the  horizontal  ramus  of  the  pubes  and  extends  backward 
to  t.ie  last  two  segments  of  the  coccyx.     The  inner  portion  of  this 


32  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

pubococcygeus,  sometimes  called  the  piiborectalis,  sends  a  few  fibers  to 
the  urethral  and  vaginal  walls;  some  to  the  tendinous  centre  of  the  peri- 
neum, while  others  pass  to  the  rectal  sheath  and  some  interlace  with  the 
fibers  of  the  external  sphincter.  Behind  the  rectum  the  inner  fibers  of 
the  two  pubococcygei  are  linked  together  by  fascial  structures  and  the 
companion  muscles  thus  united  pass  to  the  anterior  surface  of  the  coccyx 
to  be  inserted  into  the  ligamentum  sacrococcygeum  anterius.  The  outer 
portions  of  the  pubococcygei,  larger  than  the  inner,  pass  directly  from 
pubes  to  coccyx. 

The  ischiococcygeus,  the  main  portion  of  the  levator  ani  muscle,  arises 
from  the  white  line  between  the  pubes  and  s])ine  of  the  ischium  and  from 
the  spine  of  the  ischium,  and  extends  backward,  downward,  and  inward 
to  the  sides  of  the  coccyx.  It  is  thus  seen  that  the  former  idea  of  the 
levatores  ani  blending  with  each  other  behind  the  vagina  and  behind 
the  anus  and  forming  a  U-shaped  muscle  about  the  lower  ends  of  these 
canals  is  erroneous.  As  a  matter  of  fact  the  ischiococcygeus,  the  main 
portion  of  the  levator  ani,  meets  its  fellow  in  the  median  line  only  when 
it  reaches  the  coccyx. 

It  is  the  attachment  of  the  inner  fibers  of  the  jnibococcygeus  to  the 
vaginal  and  rectal  walls  and  the  linking  of  the  two  pubococcygei  in  the 
median  line  by  means  of  fascial  or  fibrous  structures  which  gives  the 
apparent  sling  action  in  elevating  the  lower  ends  of  the  rectum  and 
vagina  when  the  levatores  ani  contract. 

The  nerve  supply  of  the  levator  ani  is  from  the  fourth  sacral  and  the 
perineal  branch  of  the  pudic  nerve. 

The  Coccygeus. — The  coccygeus  is  a  thin  triangular-shaped  muscle 
which  supplements  the  levator  ani  in  completing  the  posterior  portion 
of  the  muscular  pelvic  floor. 

It  arises  on  each  side  from  the  spine  of  the  ischium  and  is  inserted  into 
the  lateral  margin  of  the  coccyx  and  the  last  segment  of  the  sacrum. 

The  coccygei  muscles  acting  with  the  levatores  ani  draw  the  coccyx 
forward  after  it  has  been  displaced  backward,  as  in  defecation  or  par- 
turition. 
^  The  nerve  supply  is  the  fourth  sacral. 

The  Pyriformis  Muscle. — The  pyriformis  muscle  on  either  side  lies 
l)ehind  the  coccygeus  and  helps  to  fill  in  the  posterior  and  lateral  portions 
of  the  pelvic  floor  but  is  of  little  obstetrical  importance. 

The  strength  of  the  pelvic  floor,  so-called,  depends  very  largely  upon 
the  layers  of  fascia  which  serve  to  unite  the  various  muscles  and  viscera 
of  the  pelvis.    This  fascia  will  now  be  described. 

The  Pelvic  Fascia. — Covering  the  levatores  ani  above  and  lining  them 
below,  are  two  sheets  of  fascia,  derived  from  the  pelvic  fascia  which  is 
a  direct  continuation  into  the  pelvis  of  the  transversalis  and  iliac  fascije 
which  belong  to  the  abdomen. 

The  layer  covering  the  upper  surface  of  this  muscular  diaphragm  is 
called  the  rectovesical  fascia  (see  Figs.  21  and  22),  and  is  the  upper  and 
inner  division  of  the  pelvic  fascia  which  separates  from  the  lower  and 
outer  division  or  ohhtrator  fascia  along  a  line  called  the  "white  line" 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 


33 


Iliacus 
Psoas  muscle         Cecum        muscle     Ilium 


Gluteus  medius 


Iliopectineal  ridge 
Gluteus  minimus 


Iliotibial  band 
Pelvic  fascia 


Obturator  int.  _ 
"White  line     -, 
Obturator  fascia    ' 
Bladder 
Rectovesical  fascia 
Levator  ani 
Anal  fascia 
Levator  ani 
Deep  layer  triang.  lig. 
Superfieial  layer 
triangular  ligament 


Fig.  21. — Coronal  section. 


Fig.  22. — Pelvic  fascia  key  corresponding  to  fascia  outlined  in  white  in  frozen  section 

in  Fig.  21. 

3 


3-4  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

already  referred  to,  extentling  from  the  posterior  surface  of  the  body 
and  ramus  of  the  pubes  in  front  to  the  spine  of  the  ischium  behind. 

This  rectovesical  fascia,  aside  from  covering  the  levatores  ani  above, 
is  continued  on  to  the  rectum,  vagina  and  bladder,  forms  the  true  liga- 
ments of  the  bladder  and  connects  the  bladder  and  rectum  to  the  vagina. 
It  adds  greatly  to  the  strength  of  the  pelvic  floor  and  thus  aids  in  the 
support  of  the  pelvic  viscera. 

The  layer  of  fascia  covering  the  under  surface  of  the  levatores  ani  is 
called  the  anal,  or  ischiorectal  fascia  and  is  derived  from  the  obturator 
fascia  soon  after  it  separates  from  the  rectovesical. 

The  obturator  fascia,  on  each  side  of  the  pelvis,  covers  the  inner  surface 
of  the  obturator  muscle,  being  attached  to  the  bony  surface  around  its 
margin,  and  forms  the  outer  wall  of  the  ischiorectal  fossa. 

The  Ischiorectal  Fossa. — The  ischiorectal  fossa  is  a  pyramidal  space  on 
each  side  of  the  pelvis,  bounded  superiorly  and  internally  by  the  levator 
ani  muscle  covered  with  the  anal  fascia,  and  externally  by  the  obturator 
muscle  covered  by  the  obturator  fascia. 

The  floor  of  this  fossa  is  formed  by  the  skin  and  fasciae,  both  superficial 
and  deep,  reinforced  and  limited  anteriorly  by  the  transversus  perinei 
muscle;  reinforced  posteriorly,  when  standing,  by  the  gluteus  maximus. 
Filling  in  the  anterior  portion  of  the  pelvic  outlet  between  the  ischiopubic 
rami  in  front  and  a  line  drawn  through  the  tuberosities  of  the  ischia 
behind  are  two  fasciae,  the  superficial  and  the  deep,  and  between  these 
fasciae  several  pairs  of  muscles  which  will  soon  be  described. 

These  fasciae  each  consist  of  two  layers,  they  are  perforated  by  the 
vagina  and  urethra  and  the  muscles  which  lie  between  them  are  placed 
on  either  side  of  the  canals  by  which  the  fasciae  are  perforated. 

The  deep  fascia,  called  the  triangular  ligament  (see  Fig.  15),  is  tri- 
angular in  shape  and  extends  from  the  pubic  arch  in  front  to  the  centre 
of  the  perineal  body  about  an  inch  in  front  of  the  anus  where  it  joins  with 
the  superficial  fascia.  This  deep  fascia  consists  of  two  layers,  the  superior 
or  deep  layer,  and  the  inferior  or  superficial  layer.  The  superior  layer 
may  be  regarded  as  an  extension  from  both  the  rectovesical  and  the 
obturator  fascia.  Between  the  superior  and  inferior  layers  of  the  tri- 
angular ligament  or  deep  fascia,  are  situated  a  portion  of  the  urethra 
which  perforates  both  layers,  the  constrictor  muscle  of  the  urethra, 
vessels,  and  nerves. 

The  superficial  fascia  also  consists  of  two  layers,  the  superficial  and 
deep. 

The  superficial  layer  lies  just  beneath  the  skin  and  is  continuous  with 
the  general  superficial  fascia  of  the  body,  it  is  loose  and  areolar  and  its 
spaces  are  occupied  by  adipose  tissue. 

The  deep  layer  of  the  superficial  fascia,  divided  in  the  median  line  by 
the  genital  orifice,  is  attached  on  each  side  to  the  rami  of  the  ischium 
and  pubes  and  extends  from  the  pubic  arch  in  front  to  the  centre  of  tlie 
perineal  body  behind,  where  it  unites  with  the  inferior  layer  of  the  tri- 
angular ligament  or  deep  fascia.  Between  this  deep  layer  of  the  super- 
ficial fascia  and  the  inferior  or  superficial  layer  of  the  triangular  ligaments 


ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS  35 

are  the  muscles  already  referred  to  and  now  to  be  described  (see  Fig.  23). 
As  the  muscles  occur  in  pairs,  one  on  either  side  of  the  median  line,  only 
one  side  will  be  spoken  of. 

The  bulbocavernosus  or  constrictor  vaginae  muscle  arises  from  the  centre 
of  the  perineal  body  where  it  fuses  with  the  sphincter  ani  and  trans- 
versus  perinei  and  passes  forward  over  the  vaginal  bulb  of  that  side 
and  is  inserted  with  its  fellow  into  the  sheaths  of  the  corpora  cavernosa 
of  the  clitoris.  Its  action  is  chiefly  to  compress  the  bulb  of  the  vestibule. 
It  has  little,  if  any,  power  in  constricting  the  vagina. 

The  ischiocavernosus  or  erector  clitoridis  muscle  (see  Fig.  23)  arises 
from  the  tuberosity  and  ramus  of  the  ischium  and  extending  forward 
is  inserted  into  the  corpus  cavernosum  of  the  clitoris.  Its  action  is  to 
compress  the  crus  clitoridis  and  so  cause  and  maintain  erection. 


Fig.  23. — Muscles  of  the  pelvic  floor,  seen  from  below. 

The  Transversus  Perinei  Muscle. — The  transversus  perinei  muscle  arises 
on  each  side  from  the  inner  surface  of  the  tuberosity  of  the  ischium, 
passes  inward  and  is  inserted  into  the  centre  of  the  perineal  body,  fusing 
there  with  its  fellow  of  the  opposite  side,  with  the  sphincter  ani  and  with 
the  bulbocavernosi  muscles. 

The  transversi  perinei  serve  to  fix  the  perineal  body  and  thus  aid  the 
action  of  the  other  muscles  inserted  into  it.  The  nerve  supply  of  the 
three  pairs  of  muscles  just  described,  the  bulbocavernosi,  the  ischio- 
cave^rnosi  and  the  transversi  perinei  is  the  perineal  branch  of  the  pudic 
nerve.  The  line  of  union  of  the  superficial  fascia  and  the  triangular 
ligament  is  along  the  posterior  border  of  the  transversi  perinei. 

The  Perineal  Body.— The  perineal  body  is  the  pyramidal  mass  of  muscle, 
fascia  and  connective  tissue  filling  in  the  space  between  the  tuberosities 
of  the  ischium  and  the  diverging  rectum  and  vagina  which  at  their 
external  openings  are  separated  about  2.5  cm.  (1  in.)  but  unite  about 
4  cm.  fl|  in.)  above  their  orifices.  The  perineal  body,  being  the  rneeting- 
point  of  most  of  the  muscles  and  fasciae  comprising  the  pelvic  floor, 


30 


ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


serves  when  intact  to  maintain  the  proper  position  and  rehition  of  the 
canals  perforating  the  pelvic  floor,  and  of  the  internal  organs  of  generation 
which  lie  above  it  The  arteries,  veins  and  nerves  of  the  pelvic  floor 
may  be  seen  in  Plate  IV. 

THE  INTERNAL  ORGANS  OF  GENERATION. 

Having  studied  the  external  generative  organs,  the  pelvic  floor  and 
the  vagina  which  perforates  it  and  connects  the  external  organs  with 
the  internal,  we  are  now  ready  for  the  study  of  the  internal  organs  of 
generation,  consisting  of  the  uterus,  Fallopian  tubes,  and  ovaries. 

The  Uterus. — The  uterus  is  a  hollow  muscular  organ,  pyriform  in 
shape,  lying  in  the  pelvis  between  the  bladder  in  front  and  the  rectum 
behind.  It  measures  approximately  2.5  cm.  (1  in.)  in  its  anteroposterior 
diameter;  nearly  4.5  cm.  (2  in.)  in  its  transverse  diameter  at  the  upper 


Fig.  24. — Fundus  of  uterus,  seen  from  above. 

or  larger  extremity  and  7.5  cm.  (3  in.)  in  length.  It  is  flattened  on 
the  anterior  surface;  much  more  convex  on  its  posterior  surface  and 
upper  extremity  (see  Fig.  24).  Slightly  below  the  middle  of  the 
uterus  there  is  seen  to  be  a  constriction  called  the  isthmus,  dividing  the 
organ  into  a  body,  that  portion  above  the  isthmus,  and  a  cervix,  that 
portion  below  it.  The  relative  length  of  cervix  and  body  depends  upon 
whether  the  uterus  is  that  of  an  infant  or  an  adult.  In  F'ig.  25,  A  was 
taken  from  an  infant  at  birth;  B  froin  a  nulliparous  woman;  C  from  a 
multipara. 

It  is  seen  that  in  the  infant  uterus  the  length  of  the  cer\'ical  canal 
is  nearly  two-thirds  that  of  the  whole  uterine  canal,  while  in  the  adult 
uterus  the  cervical  canal  is  only  about  one-third  of  the  uterine  canal. 

The  attachment  of  the  vagina  to  the  cervix  divides  the  latter  into  two 
portions:  (a)  the  infravaginal  portion  (see  Fig.  2()),  which  projects 
into  the  vagina,  and  (b)  the  supravaginal  ])ortion,  which  lies  above  it. 


PLATE  IV 


bulbus  vestibuli 


Ischiocavernosus 


art.  of  clitoris 


perineal   branches 
of  posterior    ... 
femoral  cutaneous 
nerve 


'posterior  labial 
arteries 


'Urogenital 
trigone 


-Transversus  perinei 
superficialis 


.'•'perineal  nerve 


cluneal  lit   . .  .     ^ 

Inf.  haemorrhoidal  and  perineal'    ,-• 

nerves  inlmal  pudU 

itltcnial  pudic  art.       y 

nudic  nerve 
Gluteus  marimus  X 


Levator  am 

anococcygeal  lig. 


Gluteus  maximus 
■.^  internal  pudic  vessels 

inferior  haemorrhoidal  artery 
medial  inferior  cluneal  nerve 

^ Sphincter  ani  externus 


Anatomy  of  the  Pelvic  Floor.     (Sobotta.) 


THE  INTERNAL  ORGANS  OF  GENERATION 


37 


x\s  the  vaginal  wall  is  attached  to  the  cervix  lower  in  front  than  behind, 
the  infra  vaginal  portion  of  the  cervix  is  shorter  anteriorly  than  posteriorly. 


Fig.  25. — Uteri  of  infant,  nullipara,  and  multipara. 


The  upper  convex  extremity  of  the  uterus,  lying  above  the  entrance  of 
the  Fallopian  tubes,  is  called  the  fundus.    In  practical  obstetric  work  the 
use  of  this  term  fundus  is  commonly  extended  to  apply  to  the  whole 
of  the  upper  part  of  the  uterus,  felt  through 
the  abdominal  wall.    The  lateral  angles  of 
the    uterus    marking    the    entrance  of  the 
Fallopian  tubes  are  called  the  cornua. 

The  uterus,  supported  by  the  pelvic  floor 
below  and  by  the  ligaments  above,  lies 
normally  inclined  forward  toward  the  blad- 
der; its  position,  however,  is  constantly 
changing  with  the  movements  of  respi- 
ration and  with  the  condition  of  distention 
of  bladder  and  rectum,  especially  the 
former.  Beginning  with  the  isthmus  ante- 
riorly and  extending  over  the  fundus  down 
to  the  attachment  of  the  vaginal  wall 
posteriorly,  the  uterus  is  covered  by  peri- 
toneum. 

The  cavity  of  the  uterus  extends  from 
the  opening  of  the  cervix  into  the  vagina, 
the  external  os,  to  the  inner  surface  of  the 
fundus  and  measures  about  6.25  cm.  (2|  in.)  in  length.    It  is  constricted 
about    opposite  the  isthmus  by  a  narrowing  of  the  canal  called  the 


Supravaginal')  p^^.^ion 

Of 
Infravaginal     Cervix 


Fig.  26. — Infravaginal  and  supra- 
vaginal portion  of  the  cervix. 


38  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

internal  os,  which  divides  the  cavity  of  the  body  above  from  tliat  of  the 
cervix  bek^w. 

A  coronal  section  of  the  nterns  throngli  the  tnl)es  shows  tlie  ca\ity 
of  the  body  to  be  triangular  with  the  sides  convex  inward.  The  cavity 
of  the  cervix  is  fusiform,  the  external  os  being  larger  than  the  internal, 
but  both  smaller  than  the  cavity  of  the  cer\'ix.  The  anterior  and  posterior 
walls  of  the  uterus  normally  lie  in  contact.  A  probe  3  mm.  (|  in.)  in 
diameter  will,  as  a  rule,  just  about  fit  the  internal  os  of  a  normal  virgin 
uterus. 

The  cavity  of  the  uterus  is  lined  throughout  by  mucous  membrane 
called  endometrium. 

The  uterus  is  thus  seen  to  consist  of  three  coats: 

1.  The  serous  or  peritoneal  coat. 

2.  The  muscular  coat,  which  constitutes  the  chief  thickness  of  the  organ. 

3.  The  mucous  coat  or  endometrium,  which  lines  the  uterine  cavity. 
These  coats  will  now  be  considered  more  in  detail. 

The  Serous  Coat.^ — For  a  better  understanding  of  the  serous  coat  one 
may  well  trace  the  course  of  the  peritoneum  as  it  leaves  the  anterior 
abdominal  wall  to  dip  into  the  pelvis  (see  Fig.  13).  Passing  over  the 
upper  surface  of  the  bladder  it  dips  down  between  the  bladder  and  uterus 
until  it  reaches  the  level  of  the  isthmus  whence  it  passes  to  the  uterus, 
thence  over  it,  forming  its  serous  coat,  to  the  attachment  of  the  posterior 
wall  of  the  vagina  behind.  It  passes  down  this  vaginal  wall  for  about 
an  inch  and  is  then  reflected  to  the  anterior  surface  and  sides  of  the 
rectum.  From  the  sides  of  the  uterus  the  peritoneum  is  reflected  to  the 
sides  of  the  pelvis,  covering  the  Fallopian  tubes  and  covering  and  helping 
to  form  the  ligaments  leading  from  the  uterus. 

Peritoneal  Pouches. ^ — The  peritoneum,  as  it  passes  from  the  uterus 
to  the  sides  of  the  pelvis,  divides  the  pelvic  peritoneal  cavity  into  two 
pouches:  one  between  the  uterus  and  the  bladder,  called  in  its  deeper 
portion  the  uterovesical  pouch,  and  one  between  the  uterus  and  the  rectum, 
called  in  its  deeper  portion  the  recto-ideririe  jiovch  or  the  pouch  of  Douglas. 
These  pouches  are  usually  occupied  by  coils  of  small  intestine. 

The  Muscular  Coat. — ^The  muscular  structure  of  the  uterus  constitutes 
the  chief  bulk  of  its  wall  and  is  composed  of  non-striated  muscular  fibers. 
It  is  interspersed  wuth  areolar  tissue,  bloodvessels,  and  nerves.  In  the 
unimpregnated  condition  no  distinct  arrangement  of  the  fibers  is  visible 
but  in  the  gravid  uterus  the  muscular  fibers,  generally  speaking,  are 
arranged  in  three  layers — an  external,  a  middle  and  an  internal,  all  more 
or  less  connected.  The  external  layer  is  thin  and  is  intimately  connected 
with  the  peritoneum.  It  contains  both  longitudinal  and  circular  fibers, 
the  former  predominating.  From  this  layer  fibers  pass  to  the  Fallopian 
tubes  and  the  ligaments  of  the  uterus. 

The  middle  layer  forms  the  chief  part  of  the  muscular  structure  of  the 
uterus.  Its  fibers  have  no  definite  arrangement  but  interlace  in  e^'ery 
direction  about  the  bloodvessels  which  are  very  abundant.  This  layer 
develops  greatly  in  pregnancy  and  its  contraction  is  the  chief  agent 
in  the  control  of  uterine  hemorrhage. 


THE  IXTERXAL  ORGANS  OF  GENERATION  39 

The  internal  layer  is  thin  and  is  intimately  connected  with  the  endo- 
metrium. It  contains  both  longitudinal  and  circular  fibers,  the  latter 
predominating  especially  about  the  openings  of  the  Fallopian  tubes  and 
at  the  internal  os. 

The  Mucous  Coat,  or  Endometrium. — The  mucous  coat  differs  in  the  body 
of  the  uterus  from  that  in  the  cervix.  In  the  body  it  is  smooth,  covered 
with  columnar,  ciliated  epithelial  cells,  and  presents  the  openings  of 
numerous  tubular  glands,  the  utricular  glands.  The  mucous  membrane 
rests  directly  upon  the  internal  layer  of  the  muscular  coat,  there  being 
no  submucous  layer.  The  cilise  of  the  epithelium  float  in  the  direction 
from  fundus  to  cervix.  The  utricular  glands  are  tubular  structures 
lined  with  columnar,  ciliated  epithelial  cells  similar  to  those  on  the 
surface  of  the  endometrium.  The  glands  take  a  varied  course,  straight, 
oblique,  or  spiral,  from  the  surface  of  the  endometrium  down  to  the 
muscular  coat.  ]Many  are  bifurcated  at  their  outer  extremities,  and 
these  bifurcated,  blind  extremities  abut  against  the  muscular  tissue. 

The  mucous  membrane  of  the  cervix  is  thicker  and  firmer  than  that 
of  the  body  of  the  uterus  and  is  thrown  into  numerous  folds  or  ridges, 
longitudinal  and  transverse.  On  the  anterior  and  posterior  wall  of  the 
canal  is  a  median  longitudinal  ridge  giving  the  so-called  arbor  vitae 
formation.  The  epithelium  in  the  upper  part  of  the  canal  is  columnar 
and  ciliated,  as  in  the  body  of  the  uterus.  In  the  lower  third  of  the  canal 
it  is  stratified  squamous  epithelium,  similar  to  that  covering  the  vaginal 
portion  of  the  cervix.  Aside  from  tubular  glands,  similar  to  those  of  the 
uterine  body,  there  are  found  in  the  cervical  mucosa  numerous  racemose 
glands  secreting  an  alkaline,  glairy  mucus.  By  the  occlusion  of  their 
duets  these  glands  not  infrequently  become  cystic,  forming  the  so-called 
ovula  of  Nahoth  or  Nabothia?i  follicles. 

The  epithelium  covering  the  vaginal  portion  of  the  cervix  is  of  the 
stratified  squamous  variety. 

Ligaments  of  the  Uterus. — ^The  ligaments  which  se^^•e  to  maintain 
the  position  of  the  uterus  are  six  in  number,  arranged  in  pairs:  The 
round,  the  broad,  and  the  uterosacral.  They  are  all  covered  by  folds  of 
peritoneum  and  contain  muscular  fibers  derived  from  the  uterus. 

The  round  ligaments,  about  12.5  cm.  (5  inches)  in  length,  arise  on  each 
side  of  the  uterus  in  front  of,  and  a  little  below,  the  attachment  of  the 
Fallopian  tube.  Aside  from  the  muscular  fibers  mentioned  above,  they 
contain  "areolar  tissue,  bloodvessels,  and  nerves.  The  ligaments  extend 
from  the  uterus  obliquely  forward  and  outward  to  enter  the  internal 
inguinal  rings  on  each  side.  After  traversing  the  inguinal  canals  they 
terminate  in  the  tissues  of  the  mons  veneris  and  labia  majora,  some 
fibers  being  attached  to  the  pillars  of  the  external  ring  and  the  pubic 
bone. 

The  covering  of  peritoneum  in  the  young  subject  follows  the  round 
ligament  into  the  inguinal  canal  as  a  tubular  prolongation.  E^'en  in  the 
adult  this  sometimes  remains  pervious  and  is  called  the  canal  of  Xuck. 

The  Broad  Ligaments.— The  two  folds  of  peritoneum  which  extend 
from  the  sides  of  the  uterus  and  upper  part  of  the  vagina  to  the  lateral 


40  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

walls  and  Hoor  of  the  pohis  are  called  the  broad  ligaments  of  the  uterus. 
These  two  folds  are  continuous  with  the  peritonenm  covering  the  anterior 
and  posterior  surfaces  of  the  uterus  and  the\'  themselves  meet  above 
the  Fallopian  tubes  to  form  their  covering  as  far  as  the  fimbriated 
extremity.  The  portion  of  the  broad  ligament  on  each  side  between  the 
fimbriated  extremity  of  the  P'allopian  tube  and  the  side  of  the  pelvis 
is  called  the  infundihuhpehic  ligament.  The  broad  ligaments  contain 
within  their  folds,  aside  from  the  Fallopian  tubes  which  occupy  their 
superior  border,  the  round  ligaments  in  front,  the  utero-ovarian  liga- 
ments behind,  the  remains  of  fetal  structures,  and  numerous  bloodvessels, 
lymphatics,  and  nerves. 

The  vterosacral  ligaments  are  two  folds  of  peritoneum,  reinforced  by 
muscular  fibers,  extending  from  the  upper  part  of  the  cervix  to  the  sides 
of  the  rectum  and  to  the  second  sacral  vertebra. 

As  their  muscular  fibers  are  continuous  with  the  superficial  muscular 
layer  of  the  uterus  and  vagina,  and  as  the  direction  of  the  ligaments 
is  nearly  parallel  with  that  of  the  vagina,  they  not  only  tend  to  draw 
the  cervix  backward  but  the  vagina  upward. 

The  two  uterosacral  ligaments  form  the  lateral  boundaries  of  the 
pouch  of  Douglas.  The  two  folds  of  peritoneum  extending  between  the 
cervix  and  the  sides  of  the  bladder  and  forming  the  lateral  boundaries 
of  the  uterovesical  pouch  are  sometimes  spoken  of  as  the  uterovesical 
ligaments,  but  they  are  very  unimportant. 

The  Fallopian  Tubes  or  Oviducts. — The  Fallopian  tubes  are  two 
curved  muscular  canals  10  to  12.5  cm.  (4  to  5  inches)  in  length,  leading 
from  the  ovary  on  each  side  to  the  cornu  of  the  uterus  and  serving  to 
conduct  the  ova  to  the  uterine  cavity.  Although  constantly  changing 
in  position  with  that  of  the  uterus  their  general  direction  from  the 
cornua  of  the  uterus  is  outward,  then  backward,  downward  and  in- 
ward to  be  attached  to  the  ovary  by  one  of  the  fringes  of  the  distal 
extremity. 

The  Fallopian  tube  on  each  side  from  the  cornu  of  the  uterus  to  the 
opening  near  the  ovary  lies  within  the  upper  border  of  the  peritoneal 
folds  forming  the  broad  ligament.  The  portion  of  the  broad  ligament 
between  the  Fallopian  tube  and  the  ovary  is  sometimes  called  the  meso- 
salpinx. The  Fallopian  tube  is  lined  with  mucous  membrane  continuous 
with  that  of  the  uterine  cavity.  The  tube  thus  forms  a  communication 
between  the  uterine  and  peritoneal  cavities.  The  uterine  opening  of 
the  tube,  ostium  uterinum,  is  very  small,  scarcely  large  enough  to  admit 
a  fine  bristle.  The  abdominal  opening,  osti^im  abdominale  is  expanded 
to  a  diameter  of  4  to  G  mm.  and  here  the  peritoneal  covering  of  the  tube 
joins  the  mucous  membrane  of  its  lining.  For  purposes  of  description 
the  Fallopian  tubes  are  divided  into  four  portions:  (a)  The  interstitial 
portion,  (b)  the  isthmus,  (c)  the  ampulla,  (d)  the  infundibulum,  or 
fimbriated  extremity. 

The  Interstitial  Portion. — The  interstitial  portion  is  that  part  of  the  tube 
which  is  contained  within  the  uterine  wall.  Its  lumen  is  small,  continuing 
nearlv  the  diameter  of  the  ostium  uterinum. 


THE  FALLOPIAN  TUBES 


41 


The  Isthmus. — The  isthmus  is  the  straight  horizontal  portion  of  the 
tube  3  cm.  (1  to  1 1  inches)  in  length  just  outside  the  cornu  of  the  uterus. 


Fig.  27. — Fallopian  tube  laid  open.  (After  Richard.)  a,  h,  uterine  portion  of  tube; 
c,  d,  pliese  of  mucous  membrane;  e,  tubo-ovarian  ligaments  and  fringes;  /,  ovary;  g,  round 
ligament. 


Fig.  28. — Fallopian  tube;  cross-section  through  ampulla,  under  low  power.  (After 
Luschka.)  a,  submucous  layer;  h,  muscular  layer;  c,  serous  coat;  d,  mucous  membrane; 
e,  e,  vessels;  1,1,  small  primary  folds;  2,  2,  larger  longitudinal  and  accessory  folds;  3,  3, 
small  folds  united  forming  canaUcuU. 


42  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

Its  lumen,  though  still  small,  is  larger  than  that  of  the  interstitial  portion 
and  has  a  diameter  of  about  3  mm.  (I  inch). 

The  Ampulla. — The  ampulla  is  the  dilated,  tortuous  portion  of  the  tube 
extending  from  the  isthnnis  to  the  fimbriated  extremity  and  forming 
more  than  one-half  of  the  extra-uterine  portion  of  the  tube.  Its  lumen 
gradually  increases  from  the  uterus  outward,  averaging  about  twice 
that  of  the  isthmus.  Its  walls  are  thimier  and  more  flexible  than  those 
of  the  isthmus. 

The  Infundibulum  or  Fimbriated  Extremity. — The  infundibulum  is  the 
funnel-shaped  abdominal  end  of  the  tube  surrounded  by  diverging 
fleshy  processes  or  flmbrije  (fringes)  arranged  in  two  or  three  concentric 
circles. 

One  of  the  fimbria  longer  than  the  rest  extends  from  the  infundib- 
ulum of  the  tube  to  the  neighboring  extremity  of  the  ovary.  This 
fimbria  {fimbria  ovarira)  is  grooved,  lined  with  mucous  membrane,  and 
resembles  a  gutter  leading  from  the  surface  of  the  ovary  to  the  abdominal 
opening  of  the  tube. 

As  thus  described,  the  Fallopian  tube  is  seen  to  consist  of  three  coats: 

1.  A  serous  coat,  the  peritoneal  folds  of  the  broad  ligament  which 
surround  the  tube,  save  a  narrow  strip  along  its  under  surface  where 
the  folds  approach  each  other. 

2.  A  muscular  coat,  consisting  of  two  layers,  an  outer  longitudinal 
and  an  inner  circular,  both  continuous  with  the  muscular  structure  of 
the  uterus.  A  few  fibers  of  the  longitudinal  coat  are  continued  into  the 
fimbria  ovarica  as  far  as  the  ovary. 

3.  A  mucous  coat  continuous  with  the  mucous  lining  of  the  uterus. 

The  mucous  membrane  of  the  tube  is  thrown  into  numerous  longi- 
tudinal folds,  forming  furrows,  extending  the  whole  length  of  the  canal 
(see  Fig.  27).  These  furrows  are  continued  along  the  fimbriae.  The 
mucous  membrane  is  covered  by  a  single  layer  of  columnar  ciliated  epithe- 
lial cells,  the  cilise  of  which  float  toward  the  uterus.  The  longitudinal 
folds  in  the  mucous  membrane  of  the  ampulla  are  quite  complicated,  giving 
on  transverse  section  of  the  tube  the  appearance  shown  in  Fig.  28.  Xot 
infrequently  there  is  found  attached  to  one  of  the  fimbriae  a  small  cyst 
called  the  hi/datid  of  Morgagni.  It  is  lined  with  columnar,  ciliated  epithe- 
lium, is  filled  with  a  clear  fluid,  and  is  a  relic  of  a  fetal  structure.  Accord- 
ing to  Heisler  it  is  derived  from  the  upper  series  of  Wolffian  tubules. 

The  Ovaries. — The  ovaries,  the  source  of  the  ova,  are  two  flattened, 
ovoid  bodies  lying  on  either  side  of  the  uterus  a  little  below  the  Fallopian 
tubes  and  attached  to  the  posterior  layer  of  the  broad  ligaments.  They 
vary  in  size  in  diflerent  individuals  but  in  general  each  ovary  measures 
about  4  cm.  (1|  inches)  in  length,  2  cm.  (f  inch)  in  breadth,  and  1  cm. 
(I  inch)  in  thickness,  and  weighs  from  1  to  2  drams  (4  to  8  gms.). 
The  anterior  attached  border  is  nearly  straight  and  is  called  the  hiluvi. 
It  is  here  that  the  bloodvessels  and  nerves  enter  the  ovary  from  between 
the  layers  of  the  broad  ligament.  The  posterior  border  is  convex  and 
projects  into  the  peritoneal  cavity.  The  outer  extremity  of  the  ovary 
is  broad  and  convex;  the  inner  is  narrow  and  is  continued  into  the  utero- 


THE  INTERNAL  ORGANS  OF  GENERATION 


43 


ovarian  ligament,  a  rounded  cord  about  3  cm.  (1  incli)  in  length  running 
between  the  folds  of  the  broad  ligament  and  connecting  the  ovary  with 
the  uterus  a  little  behind  and  below  the  origin  of  the  Fallopian  tube. 
This  ligament  contains  muscular  fibers  derived  from  the  muscular 
structure  of  the  uterus.  The  ovary  is  further  maintained  in  position 
by  the  fimbria  ovarica,  sometimes  called  the  hihodmrian  ligament,  con- 
necting it  with  the  tube;  and  by  the  infundibulopelvic  or  suspensory 
ligament  connecting  it  with  the  side  of  the  pelvis.  Except  at  its 
attached  border  the  ovary  is  covered  by  modified  peritoneum  called 
germinal  epithelium. 

On  section  of  the  ovary  its  structure  is  seen  to  differ  in  its  periphery 
from  that  of  its  central  portion. 


Fig.  29. — Diagrammatic  cross-section  of  a  vertebrate  to  show  the  fundamental-relations 
of  the  ui-ogenital  S5-stem.  Md,  medullary  tube;  Nch,  notochord;  Ao,  aorta;  B,  genital 
ridge;  W.D,  Wolffian  duct;  M.D,  Miiller's  duct;  A,  W^olffian  ridge;  Msth,  mesothelium;  Coe, 
celom;  Som,  somatopleure ;  Ach,  archenteron.     (Minot.) 

The  periphery  is  less  vascular,  contains  the  Graafian  follicles  and  ova, 
and  is  called  the  cortex. 

The  central  portion,  rich  in  bloodvessels  and  nerves  but  containing 
no  Graafian  follicles,  is  called  the  medulla. 

The  stroma  of  the  ovary  consists  of  a  connective-tissue  framework 
containing  numerous  spindle-shaped  cehs.  This  stroma  is  more  dense 
in  the  cortex  than  in  the  medulla.  The  surface  of  the  ovary  is  covered 
by  so-called  germinal  epithelium,  composted  of  a  single  layer  of  columnar 
cells,  thus  differing  from  the  mesothelium  which  it  joins  at  the  attached 
border  of  the  ovary.  After  puberty  the  surface  of  the  ovary  is  irregular, 
due  to  the  projections  of  the  developing  Graafian  follicles  situated  in 
the  cortex  and  to  the  depressions  caused  by  their  rupture  and  cicatrization. 

On  account  of  the  condensation  of  the  cehs  of  the  stroma  at  the  per- 
iphery of  the  cortex  this  layer  is  called  the  tunica  albuginea.    It  bears. 


44 


ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


however,  l)ut  a  sliglit  resemblance  to  the  tunica  albuginea  of  the  testicle 
and  must  not  be  considered  as  a  distinct  envelope.  (The  Graafian 
follicles  will  be  described  in  the  chapter  on  Embryology,  page  55).  A 
better  understanding  of  the  ovary  and  the  parovarium  with  their  relation 
to  the  Fallopian  tube  on  each  side  of  the  uterus  will  be  gained  by  a  brief 
study  of  their  histogenesis. 

About  the  fifth  week  of  intra-uterine  life  there  is  found  in  the  human 
fetus  on  the  posterior  wall  of  the  body  cavity  two  ridges  on  each  side 
of  the  median  line,  see  Fig.  29.  The  outer  of  these  two  ridges  (A)  is  called 
the  Wolffian  ridge  and  leads  to  the  formation  of  the  kidney.  The  inner 
(B)  is  called  the  genital  ridge  which  develops  in  the  female  into  the  ovary; 
in  the  male  into  the  testicle.  This  genital  ridge  is  formed  by  a  localized 
thickening  of  the  mesothelial  cells  lining  the  body  cavity  and  an  increase 
of  the  connective-tissue  stroma  beneath.  The  mesothelial  cells  covering 
the  surface  of  this  genital  ridge  become  modified  in  character,  penetrate 
the  ridge  and  eventually  give  rise  to  the  germ  cells,  viz.,  the  ova.  For 
this  reason  they  were  called  by  Waldeyer  the  germinal  epithelium. 


Fig.  30. — Fallopian  tube  and  the  parovarium  (diagrammatic).  A,  oophoron;  B,  paro- 
ophoron; C,  vertical  tubes  of  the  parovarium;  K,  Kobelt's  tubes;  G,  Gartner's  duct. 
(Redrawn  from  Bland  Sutton.) 


Wolffian  Body;  Wolffian  Duct.  The  Parovarium. — From  the  Wolffian 
ridge,  the  outer  of  the  two  ridges  at  the  back  of  the  body  cavity  of  the 
embryo,  are  developed  the  Wolffian  body  and  the  Wolffian  duct.  These 
have  a  diiTerent  destiny  and  importance  in  the  two  sexes.  In  the  female 
they  are  rudimentary  and  unimportant  (see  Plate  V). 

In  the  male  they  are  of  great  functional  importance.  In  both  sexes 
they  remain  intimately  connected  with  the  sexual  glands.  The  middle 
series  of  Wolffian  tubules  together  with  the  Wolffian  duct,  which  in 
the  male  develops  into  the  epididymis,  in  the  female  become  an  atrophic 
structure  known  under  different  names :  the  parovarium,  epoophoron,  or 
organ  of  RosenmuUer. 

The  Parovarium. — This  structure  on  each  side  of  the  pelvis  lies  between 
the  folds  of  tliat  portion  of  the  broad  ligament  situated  between  the 
Fallopian  tube  and  the  ovary,  called  the  mesosalpinx  (see  Fig.  30).  It 
consists  of  a  larger  horizontal  tube,  representing  a  portion  of  the  Wolffian 
duct,  and  a  series  of  shorter  vertical  tubes  which  join  it.    These  shorter 


ARTERIAL  SUPPLY  OF   THE  GENERATIVE  ORGANS  45 

tubes  converge  toward  the  hilum  of  the  ovary  to  which  they  are  attached. 
The  horizontal  tube  Hes  parallel  to  the  Fallopian  tube  and  nearer  to  it 
than  to  the  ovary.  It  usually  disappears  before  reaching  the  uterus  but 
occasionally  persists  as  a  canal  to  be  traced  down  along  the  side  of  the 
uterus  to  be  lost  upon  the  vaginal  wall,  or  it  is  occasionally  found  within 
the  wall  of  the  uterus  itself.  When  persisting  as  a  pervious  canal  in  the 
above  manner  it  is  called  the  dud  of  Gartner  and  is  occasionally  the  seat 
of  retention  cysts. 

The  lower  series  of  small  Wolffian  tubules,  which  in  the  male  become 
the  paradidymis  or  organ  of  Giraldes,  in  the  female  form  a  similar 
atrophic  structure  called  the  paroophoron. 


OVARIAN 
ARTERY*  VEIN 


^UTERINE 
ARTERY&VEiN 


Fig.  .31. — Vascular  supply  of  the  uterus  and  ovary. 

ARTERIAL    SUPPLY   OF    THE    GENERATIVE    ORGANS. 

The  arteries  of  the  external  organs  of  generation  and  the  vagina  are 
all  derived  from  the  internal  iliacs,  or  their  branches.  The  external 
organs,  comprising  the  vulva,  are  supplied  by  the  external  and  internal 
pudics  (see  Plate  IV) . 

"The  vaginal  artery,  corresponding  to  the  inferior  vesical  in  the 
male,  runs  along  the  lateral  borders  of  the  vagina,  supplying  arteries 
to  the  anterior  and  posterior  surfaces.  A  small  vaginal  branch  from  the 
uterine  and  anastomosing  branches  from  the  remaining  vesicals,  middle 
hemorrhoidal  and  internal  pudic  are  also  suppHed."    (Gerrish.) 

The  arterial  supply  of  the  uterus  is  derived  on  each  side  of  the  pelvis 
chiefly  from  the  uterine,  a  branch  of  the  anterior  division  of  the  internal 
iliac,  and  from  the  ovarian,  a  branch  of  the  abdominal  aorta  (see  Fig.  31). 


40  ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 

The  uterine  artery  passes  along  the  pelvic  wall  to  the  back  of  the 
l)roa(l  ligament,  then  crossing  in  front  of  the  ureter  passes  to  the  side 
of  the  cervix  near  the  level  of  the  vaginal  attachment.  Giving  off  several 
branches  to  the  vagina  it  passes  up  along  the  side  of  the  uterus  to  the 
fundus  where  it  anastomoses  freely  with  the  ovarian  artery.  In  its 
course  upward  it  gives  off  numerous  tortuous,  transverse  branches  to 
the  anterior  and  posterior  surfaces  of  the  uterus  which  anastomose  with 
corresponding  branches  from  the  opposite  side.  Near  the  level  of  the 
isthmus  the  circular  artery  is  formed  by  the  anastomosis  of  the  trans- 
verse branches  which  are  here  larger  than  elsewhere.  The  ovarian  artery 
arising  from  the  abdominal  aorta  passes  between  the  folds  of  the  broad 
ligament  near  its  upper  border  and  after  giving  off  branches  to  the  ovary 
and  tube,  passes  to  the  cornu  of  the  uterus  and  anastomoses  with  the 
uterine  artery. 

The  ovaries  and  Fallopian  tubes  are  supplied  with  arterial  blood  by 
the  ovarian  arteries  on  their  way  toward  the  fundus  of  the  uterus. 

VEINS   OF   THE   GENERATIVE   ORGANS. 

The  veins  of  the  external  organs  of  generation  are  abundant  and  as 
a  rule  correspond  to  the  arteries  (see  Plate  IV).  They  communicate  with 
the  vaginal  veins  w^hich  surround  the  vagina  and  are  especially  abundant 
at  the  lateral  borders  where  they  form  the  vaginal  plexuses.  These  plexuses 
communicate  freely  with  the  vesical  and  hemorrhoidal  plexuses  and  with 
the  veins  of  the  broad  ligament,  and  finally  empty  into  the  internal 
iliac  vein.  The  veins  of  the  vulva  are  frequently  the  seat  of  marked 
varicosities  during  pregnancy.  The  veins  of  the  uterus,  always  abun- 
dant and  large,  are  much  increased  during  pregnancy,  forming  the  uterine 
sinuses  within  the  muscular  structure  of  the  uterus.  These  uterine  ^'eins 
are  directed  to  the  lateral  borders  of  the  uterus  where  they  form  on 
each  side  the  uterine  plexus  from  which  a  portion  of  the  blood  through 
the  uterine  vein  is  directed  into  the  internal  iliac  vein.  The  remainder 
(save  that  which  follows  the  funicular  artery  in  the  funicular  vein) 
joins  with  the  blood  from  the  Fallopian  tube  and  ovary  in  the  plexus 
about  the  ovary  called  the  pampiniform  plexus.  From  the  pampiniform 
plexus  the  blood  is  directed,  on  the  right  side  into  the  inferior  vena  cava, 
on  the  left  side  into  the  left  renal  vein.  The  veins  of  the  generative 
organs  contain  no  valves. 

LYMPHATIC    SUPPLY    OF    THE    GENERATIVE    ORGANS. 

The  lymphatics  from  the  vulva  and  the  lower  fourth  of  the  vagina 
empty  into  the  inguinal  glands.  Those  from  the  upper  three-fourths  of 
the  vagina  join  with  those  from  the  cervix  to  empty  into  tlie  internal 
iliac  and  sacral  glands. 

The  lymphatic  supply  of  the  uterus  is  always  abundant,  and  like  the 
veins,  much  increased  during  pregnancy.  This  is  important  to  the 
obstetrician  as  emphasizing  the  danger  of  infection  and  explaining  one 


PLATE  V 


Sinus  Poculo.r'i^ 


Diagrammatic  representation  of  the  development  of  the  genito-urmary 
system  the  Wolffian  body  and  its  derivatives  being  colored  red,  the  Muilerian 
duet  and  its  derivatives,  green:  1,  indifferent  type;  2,  indifferent  type,  later 
stage  the  Wolffian  and  Muilerian  duets  and  the  primitive  ureter  now  opemng 
into  the  urogenital  sinus;  S,  male  type,  lower  ends  of  Muilerian  duets  fused 
to  form  the  sinus  pocularis;   4,  female  type.     (Heisler.) 


DEVELOPMENT  OF  FALLOPIAN  TUBES,  UTERUS  AND  VAGINA     47 

of  the  avenues  of  its  conveyance.  Beginning  in  the  lymph  spaces  of  the 
mucous  membrane  and  joining  with  the  lymphatics  of  the  muscular  wall 
of  the  uterus,  the  lymph  channels  of  the  uterus  form  a  rich  plexus  cover- 
ing the  surface  just  beneath  the  peritoneum.  The  lymphatics  from  the 
body  of  the  uterus  join  with  those  from  the  Fallopian  tubes  and  ovaries 
to  terminate  in  the  lumbar  glands.  Lymphatics  from  each  uterine 
cornu  follow  the  round  ligament  to  the  deep  inguinal  gland.  A  lymph 
node  is  usually  found  in  the  base  of  the  broad  ligament. 

NERVES    OF    THE    GENERATIVE    ORGANS. 

The  generative  organs,  both  external  and  internal,  receive  their  nerve 
supply  from  the  inferior  hypogastric  or  pelvic  plexuses.  These  are  two 
plexuses  lying  on  each  side  of  the  rectum,  vagina  and  bladder  and  are 
formed  by  the  bifurcation  and  continuation  of  the  hypogastric  plexus, 
situated  in  front  of  the  promontory  of  the  sacrum;  by  branches  of  the 
second,  third  and  fourth  sacral  nerves  and  by  a  few  fibers  from  the 
sacral  ganglia. 

The  branches  from  these  plexuses  to  the  generative  organs  largely 
accompany  the  branches  of  the  internal  iliac  artery.  The  Fallopian  tubes 
and  ovaries,  in  addition  to  the  inferior  hypogastric  or  pelvic  plexuses,  are 
supplied  by  the  ovarian  plexuses  derived  from  the  renal  and  aortic. 

The  origin  of  the  ovary  and  the  Graafian  follicle  from  the  genital 
ridge  and  the  germinal  epithelium,  and  the  origin  of  the  parovarium  and 
paroophoron  from  the  Wolffian  tubules  and  duct  have  already  been 
referred  to.  The  student  should  now  study  briefly  the  origin  of  the 
Fallopian  tubes,  the  uterus  and  the  vagina. 

DEVELOPMENT  OF  THE  FALLOPIAN  TUBES,  UTERUS  AND 

VAGINA. 

During  the  development  of  the  Wolffian  body  there  appears  lying 
parallel  with,  and  to  the  outer  side  of,  the  Wolffian  duct,  on  each  side 
of  the  body  cavity,  a  tube  called  the  dud  of  Midler,  the  exact  origin 
of  which  is  under  dispute.  By  the  descent  and  rotation  of  the  broad 
ligament  the  duct  of  Midler  which  is  external  to  the  Wolffian  duct  above, 
is  internal  to  it  below.  The  upper  end  of  this  duct  (see  Plate  V)  com- 
municates by  means  of  an  expanded  funnel-shaped  opening  with  the 
body  cavity.  The  lower  end  of  each  duct  of  Miiller  opens  into  a  cloaca 
in  common  with  the  Wolffian  ducts  and  the  intestine.  The  further 
development  of  the  lower  end  of  this  duct  will  be  studied  with  the  devel- 
opment of  the  external  generative  organs.  For  the  present  it  is  sufficient 
to  understand  that  by  the  union  and  fusion  of  the  lower  portions  of  these 
ducts  are  formed  the  vagina  and  uterus  and  that  the  upper  ununited 
portions  constitute  the  Fallopian  tubes  or  oviducts;  the  fimbriated 
extremities  being  formed  by  the  trumpet-shaped  expansion  of  the  upper 
ends  of  the  ducts.  Realizing  that  by  the  complete  fusion  of  the  lower 
portions  of  the  ducts  of  Miiller  and  the  disappearance  of  the  partition 


48 


ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


walls  formed  hy  their  approximation,  the  perfect  vagina  and  litems  are 
formed,  it  is  easy  to  understand  how  any  fault  in  this  fusion  and  absorp- 
tion process  will  produce  a  malformed  Aagina  and  uterus  in  the  shape  of 
bands  or  septa  dividinji;  the  canals  to  a  greater  or  less  extent. 

Until  about  the  fifth  month  the  embryonic  vagina  and  uterus  persist 
as  a  single  pouch-like  structure,  the  two  organs  not  being  difi'erentiated. 
At  this  time  the  development  of  a  circular  ridge  in  the  wall  of  the  pouch 
divides  them;  the  part  above  the  ridge  developing  the  thick  muscular 
wall  of  the  future  uterus;  the  part  below  the  ridge  remaining  thin- 
walled  and  more  roomy,  the  future  vagina. 

The  uterus  of  the  third  month  is  bilobed  at  its  upper  extremity,  a 
condition  persisting  as  the  normal  condition  in  certain  animals  and 
sometimes  found  as  an  abnormality  in  the  human  subject. 


Fig.  32. — Uterus  didelphys:  a,  right  cavity;  b,  left  cavity;  c,  right  ovary;  d,  right  round 
ligament;  e,  left  round  ligament;  /,  left  tube;  g,  left  vaginal  portion;  h,  right  vaginal  portion; 
i,  right  vagina;  j,  left  vagina;  A',  partition  between  the  two  vaginae.     (Mann.) 


While  all  grades  of  maldevelopment  may  be  found  in  the  uterus  and 
vagina  from  a  complete  separation  of  the  right  and  left  halves,  the 
double  uterus  and  vagina,  to  a  slight  indentation  of  the  fundus  of  the 
uterus,  or  a  band  across  the  vagina,  only  those  malformations  will  be 
described  which  are  typical,  well  marked,  and  not  very  rarely  met  with. 

The  Uterus  Didelphys. — In  this  malformation  (see  Fig.  32)  there  are 
two  separate  uteri,  each  representing  one-half  of  the  normal  organ, 
there  being  a  complete  absence  of  union  and  fusion  of  the  ducts  of 
Miiller  in  that  part  of  their  course  where  such  union  and  fusion  should 
take  place. 

Uterus  Bicornis. — In  the  uterus  hicornis  (see  Fig.  33)  the  luiion  and 
fusion  of  the  ducts  of  Miiller  are  complete  below,  forming  a  normal 
vagina  and  normal  lower  portion  of  the  uterus,  but  the  ducts  remain 


DEVELOPMENT  OF  FALLOPIAN  TUBES,  UTERUS  AND  VAGINA     49 


Fig.  34. — Uterus  septus,  completely  double  uterus,  and  incompletely  double  vagina  of  a 
girl,  aged  twenty-two  years:  o,  a,  tubes;  b,  b,  fundus  of  the  double  uterus;  c,  c,  c,  partition  of 
uterus;  d,  d,  ca^dties  of  the  uterine  bodies;  e,  e,  internal  orifices;/,/,  external  walls  of  the  two 
necks;  g,  g,  external  orifices;  h,  h,  vaginal  canals;  {,  partition  which  di^-ided  the  upper  third 
of  the  vagina  into  two  halves.  (Mann.) 
4 


50 


ANATOMY  OF   THE  FEMALE  GENERATIVE  ORGANS 


separate  above,  forming  a  double-honied  uterus  with  a  sulcus  extern- 
ally between  the  rornua  and  a  partition  internally  dividing  the  upper 
portion  of  the  uterine  cavity. 

Uterus  Septus. — In  the  uterus  sejjius  (see  Fig.  o4),  union  and  fusion  of 
the  ducts  of  ]\Iiiller  have  been  complete  so  far  as  the  external  appearance 
of  the  uterus  is  concerned,  but  a  septum  dividing  the  cavity  of  the  uterus 
or  uterus  and  vagina  shows  a  fault  in  the  absorption  of  the  partition 
formed  by  the  imion  of  the  walls  of  the  two  ducts. 

The  uterus  unicornis  (see  Fig.  35)  is  formed  by  the  development  of 
one  of  the  ducts  of  ^Iiiller  while  the  other  is  rudimentary  or  absent. 

The  above  typical  malformations  of  the  uterus  are  important  to  the 
obstetrician  as  leading  to  possible  confusion  in  diagnosis  or  to  compli- 
cations of  parturition. 

The  Mammary  Glands. — The  mammary  glands,  or  lireasts  of  the 
human  female,  bear  such  a  close  functional  relation  to  the  generative 
organs  and  their  changes  and  care  so  greatly  concern  the  obstetrician, 
that  a  brief  description  of  them  will  here  be  given. 


Fig.  35. — Uterus  unicornis.  LH,  left  horn;  LT,  left  tube;  Lo,  left  ovary;  RH,  right  horn; 
RT,  right  tube;  Ro,  right  ovary;  RLr,  right  round  ligament;  LLr,  left  round  ligament. 
(Mann.) 


The  mammary  glands  may  be  considered  as  collections  of  highly 
specialized,  highly  developed  sebaceous  glands,  whose  secretion  is 
de\'oted  not  to  purposes  of  lubrication,  but  to  nutrition.  In  the  well- 
developed  virgin  after  puberty  they  appear  as  hemispherical  masses 
presenting  a  little  below  the  centre  of  the  convexity  a  projection  called 
the  nipple,  or  mammilla,  surrounded  by  a  circular  area  of  modified 
integument  of  a  darker  color  than  that  covering  the  remainder  of  the 
breast.  The  size  of  the  breasts  varies  greatly  in  different  individuals, 
depending  largely  on  the  development  of  the  gland  tissue  proper  and  on 
the  amount  of  adipose  tissue  surrounding  it.  The  left  breast  is  usually 
a  little  larger  than  the  right.  While  usually  hemispherical  in  shape  and 
prominent  in  the  virgin,  they  are  usually  more  or  less  pendulous  in 
those  who  have  borne  children. 

The  breast  usually  covers  on  each  side  of  the  median  line  a  nearly 
circular  space  extending  from  the  sternal  border  to  the  anterior  axillary 


THE  MAMMARY  GLANDS 


51 


margin,  and  from  the  second  to  the  sixth  rib.  The  nipple  is  usually 
situated  at  about  the  level  of  the  fourth  rib.  The  color  of  the  nipple 
and  of  the  areola  varies  from  a  rosy  pink  in  the  blonde  to  a  delicate 
brown  in  the  brunette. 

The  skin  of  the  nipple  and  of  the  areola  differs  from  that  of  the  rest 
of  the  body.  That  of  the  nipple  is  wrinkled,  is  beset  with  numerous 
sensitive  papillae,  and  its  summit  presents  the  opening  of  the  lactiferous 
ducts.  The  nipple,  unlike  the  areola,  has  neither  sweat  glands  nor  hairs. 
The  skin  of  the  areola  resembles  that  of  the  nipple  but  is  more  delicate 
in  texture.  Dotted  over  the  surface  of  the  areola  are  numerous 
sebaceous  glands  which  become  much  enlarged  during  pregnancy  and 
present  the  appearance  of  small  tubercles  called  the  tnhercles  or  glands 
of  Montgomery. 


Fig.  36. — Breast,  showing  lobes,  lubules  and  lactiferous  ducts. 

The  nipple  and  areola  are  vascular  and  among  the  vessels  are  numerous 
unstriped  muscular  fibers,  both  circular  and  longitudinal,  especially  the 
former.  The  contraction  of  these  circular  fibers,  under  the  stimulus  of 
mechanical  or  other  irritation,  causes  the  nipple  and  areola  to  become 
more  prominent  and  undergo  a  sort  of  erection. 

The  secreting  structure  of  the  breast  consists  of  from  fifteen  to  twenty 
separate  lobes.  Each  lobe  is  a  compound  racemose  gland  and  consists 
of  a  number  of  lobules.  Each  lobule  consists  of  acini  or  alveoli  sur- 
rounding a  central  canal.  The  canals  from  the  lobules  unite  to  form  the 
excretory  ducts  of  the  lobes,  fifteen  to  twenty  in  number,  called  the 
lactiferous  or  gaJactoyhoroiis  duds  (see  Fig.  36). 

These  lactiferous  ducts  converge  toward  the  nipple  and  on  reaching 
the  areola  each  dilates  into  a  sinus  or  amimUa  which  serves  as  a  reservoir 


52  ANATOMY  OF  THE  FEMALE  GENERATIVE  ORGANS 

for  the  milk.  At  the  base  of  the  nipple  the  duct  becomes  contracted 
and  pursues  a  straight  course  to  the  summit  where  it  terminates  in  a 
contracted  orifice.  Aside  from  the  lobes  of  the  gland  proper,  there 
may  be  found  near  the  base  of  the  nipple  minute  glandular  bodies  called 
accessory  milk  glands  whose  ducts  open  independently  upon  the  surface 
of  the  areola  or  may  empty  into  the  ducts  traversing  the  nipple. 

The  walls  of  the  ducts  are  composed  of  areolar  tissue  containing  both 
longitudinal  and  circular  elastic  fibers  and  in  the  larger  ducts  are  un- 
striped  muscular  fibers.  The  epithelial  lining  of  the  ducts  is  continuous 
at  the  summit  of  the  nipple  with  the  integument.  The  epithelium  varies 
in  different  parts  of  the  gland.  Near  the  orifice  of  the  ducts  it  is  of  the 
squamous  variety,  while  in  the  deeper  portions  of  the  gland  the  epithe- 
lium is  columnar.  The  secreting  structure  of  the  breast  is  supported  by 
a  framework  of  fibrous  tissue  which  invests  the  entire  surface  of  the 


Fig.  37. — Supernumerary  mammary  gland  in  axilla. 

organ,  sends  processes  inward  between  the  lobes  and  lobules,  and  out- 
ward to  the  under  surface  of  the  skin.  Adipose  tissue  surrounds  the 
surface  of  the  breast,  save  immediately  beneath  the  areola  and  nipple, 
and  occupies  the  space  between  the  lobes  and  lobules. 

Supernumerary  mammary  glands  (polymastia),  either  with  or  without 
nipples,  occasionally  occur.  It  is  quite  common  to  find  in  the  axilla, 
as  shown  in  Fig.  37,  a  mass  of  mammary-gland  tissue  which  enlarges 
as  the  breast  becomes  engorged  with  the  establishment  of  lactation. 
There  is  usually,  however,  no  nipple  present  on  this  axillary  swelling, 
and  although  it  may  feel  hot  and  painful  for  a  short  time  it  speedily 
subsides  either  without  treatment  or  with  simply  the  application  of  an 
ice-bag. 

The  author  has  met  with  a  number  of  instances  where  a  supernumerary 
nipple  as  seen  in  Fig.  38  was  located  either  on  the  breast  or  on  the  ante- 


THE  MAMMARY  GLANDS  53 

rior  wall  of  the  chest.  Often  these  nipples  are  thought  by  the  patients 
to  be  warts  or  moles  and  their  true  structure  is  only  determined  when 
lactation  is  established  and  it  is  found  that  milk  can  be  expressed  from 
them. 

Aside  from  being  found  in  the  axilla  and  on  the  anterior  wall  of  the 
chest,  supernmnerary  mammary  glands  sometimes  occur  on  the  thigh 
or  on  the  back.  In  a  case  reported  by  Hirst  the  woman  had  nine  mammae 
and  as  many  nipples. 


Fig.  38. — Supernumerary  nipple. 

The  arterial  supply  of  the  breast  is  from  the  thoracic  branches  of  the 
axillary,  the  internal  mammary  and  the  intercostals.  The  veins  corre- 
spond to,  and  for  the  most  part  accompany,  the  arteries;  the  superficial 
veins  are  especially  prominent  during  the  latter  months  of  pregnancy 
and  lactation. 

The  Ijrmphatics  for  the  most  part  empty  into  the  axillary  glands,  al- 
though a  few  from  the  inner  side  of  the  breast  perforate  the  intercostal 
spaces  and  empty  into  the  mediastinal  glands. 

The  nerve  supply  of  the  breast  is  chiefly  from  the  intercostal  nerves 
through  their  cutaneous  branches. 


CHAPTER  II. 

EMBRYOLOGY  AM)   PHYSIOLOGY. 

For  an  understandinji;  of  the  process  of  fertilization  and  develo})ment 
of  the  ovum,  a  study  of  the  sjerm  cells  is  essential. 

THE   GERM   CELLS. 

The  cells  composing  multicellular  animals  {meiazoa)  fall  into  two 
categories:  (1)  the  cells  which  make  up  the  various  tissues  and  organs 
of  the  body,  ser\ing  the  purposes  of  the  individual  and  then  perishing 
without  descendant,  and  (2)  the  cells  which  serve  to  perpetuate  the 
species,  playing  a  subordinate  role  in  the  general  economy  of  the  indi- 
vidual. The  cells  of  the  first  class  are  spoken  of  as  the  somatic  cells 
(soma,  body)  in  contradistinction  to  those  of  the  second  class  which 
constitute  the  germ  cells  or  sex  cells. 

In  the  higher  animals  the  germ  cells  are  found  in  the  organs  of  repro- 
duction, from  which  they  are  eventually  discharged  and  form,  under 
certain  conditions,  the  starting-point  of  a  new  individual.  Furthermore, 
the  germ  cells  differ  widely  in  the  two  sexes,  manifesting  a  fundamental 
physiological  division  of  labor.  The  germ  cell  of  the  female  (ovum, 
ovium),  produced  in  the  ovary,  is  a  large,  relatively  non-motile  cell 
containing  nutritive  materials  in  the  form  of  fatty  substances  (yolk, 
deutoplasm).  The  germ  cell  of  the  male  (spermium,  spermatozoon), 
produced  in  the  testis,  is  an  extremely  small  cell  unencmnbered  by 
non-protoplasmic  substances  and  possessing  a  high  degree  of  motility. 

The  Ovum. — The  mature  human  ovum  has  not  yet  been  observed. 
The  description  that  follows  applies  to  the  female  germ  cell  in  a  well- 
developed  Graafian  follicle  in  the  ovary,  and  which  is  properly  called  a 
primarv  oocyte.  The  significance  of  the  mature  ovum  will  appear  in 
the  section  on  "maturation." 

With  the  exception  of  some  of  the  large  nerve  cells,  the  primary  oocyte 
is  the  largest  cell  in  the  human  body.  It  measures  approximately  250 
micra  (0.25  mm.)  in  diameter.  The  living  egg-cell,  as  described  by 
Xagel  (Fig.  .39),  is  spherical  in  shape  and  more  transparent  than  cells 
in  general.  The  cytoplasm  (ooplasm)  can  be  divided  into  two  regions: 
a  central,  somewhat  opaque  region  in  which  highly  refractive  and  feebly 
refractive  yolk  granules  of  various  sizes  are  seen,  and  a  marginal  region 
which  is  more  transparent  and  much  more  finely  granular.  The  outer 
region  contains  the  nucleus  (germinal  vesicle)  which  appears  nearly 
homogeneous.  Within  the  nucleus  is  a  distinct  nucleolus  (plasmosome) 
in  which  Xagel  was  able  to  observe  ameboid  mo^•ement.  Surroimding 
(54) 


THE  GERM  CELLS  55 

the  egg-cell  is  a  thick,  transparent  membrane,  the  zona  pellucida,  which 
shows  fine  radial  striations.  It  has  been  thought  that  these  striations 
represent  minute  canals  permitting  the  passage  of  food  substances  to 
the  ovum.  Nagel  figures  a  thin  cleft  between  the  egg-cell  and  the  zona 
pellucida  and  calls  it  the  perivitelline  space.  Some  other  observers  dis- 
pute this  on  the  ground  that  in  the  case  of  a  ruptured  ovum  the  cyto- 
plasm clings  to  the  zona  pellucida.  The  clear  membrane  is  in  turn 
surrounded  by  radially  arranged  cells,  derived  from  the  germ  hill  of  the 
Graafian  follicle  and  constituting  the  corona  radiata. 

Stained  sections  of  the  human  primary  oocyte  exhibit  structures  only 
slightly  different  from  those  of  the  fresh  cell.  The  corona  radiata,  zona 
pellucida,  outer  and  inner  zones  of  the  cytoplasm,  and  the  nucleus  are 
all  clearly  shown.  The  nuclear  membrane  is  distinct  and  within  the 
nucleus  is  a  well-marked  plasmosome,  while  the  chromatin  is  rather 
scanty.    A  centrosome  has  never  been  observed  in  the  human  egg-cell. 


Perivitelline 
space 


Germ  hill 


rff 


pellucida  c^ "  ',       -    )  _..-..—-- ,  radiata 


Zona    "   "^^  /  V!^\  Corona 


Protoplasmic  _  ■...  ... 

zone  ■  ■ ,.  's^ii}'  Nucleus 


Deutoplasmic 
zone 


Fig.  39. — Ovum  and  some  of  the  surrounding  follicular  cells  from  the  ovary  of  a  woman 
twenty-seven  years  old.  .  (Nagel.) 

The  Graafian  Follicle. — The  Graafian  follicle  (Fig.  40),  at  or  near  its 
maturity,  is  a  spherical  vesicle  located  in  the  stroma  of  the  ovary,  and 
measures  8  to  12  millimeters  in  diameter.  It  consists  of  a  wall  of  epi- 
thelium enclosing  a  cavity  filled  with  fluid.  The  greater  part  of  the 
wall  is  composed  of  several  layers  of  granular  cells  and  is  known  as  the 
stratum  granulosum.  At  one  point  the  wall  is  considerably  thickened 
and  protrudes  into  the  cavity  of  the  follicle.  This  thickening  is  known 
as  the  germ  hill  (discus  proligerus,  cumulus  ovigerus),  and  within  it  is 
embedded  the  ovum.  The  cells  immediately  surrounding  the  ovum 
are  radially  disposed  and  constitute  the  corona  radiata  (Fig.  39).  The 
follicular  cavity  is  often  spoken  of  as  the  antrum,  and  the  contained 


56 


EMBRYOLOGY  AND  PHYSIOLOGY 


fluid  is  known  as  the  liquor  folliculi.  The  folHcle  is  surrounded  by  a 
double  layer  of  connective  tissue,  a  differentiated  part  of  the  ovarian 
stroma,  the  inner  layer  being  markedly  vascular  and  the  outer  layer 
densely  fibrous.    These  two  layers  constitute  the  theca  folliculi. 


-     3 


Fig.  40. — From  a  section  of  the  ovary  of  a  girl  twelve  years  old,  showing  a  well-developed 
Graafian  follicle.  Photograph.  1,  stratum  granulosum;  £,  germ  hill  containing  the  ovum; 
3,  follicular  cavity;  4,  theca  folliculi;  5,  ovarian  stroma. 

At  its  maturity  the  Graafian  follicle  usually  occupies  the  entire  thick- 
ness of  the  ovarian  cortex,  and  produces  a  rounded  eminence  on  the 
surface  of  the  wall,  its  theca  at  one  point  merging  with  the  tunica  albu- 
ginea.  Thinning  of  the  tunica  albuginea  and  of  the  follicular  wall  nearest 
the  surface  of  the  ovary,  along  with  the  general  vascular  congestion  of  the 
ovary  and  greater  pressure  within  the  follicle  due  to  increase  in  the 
liquor  folliculi,  results  in  the  rupture  of  the  follicle  and  surface  tissues 


THE  GERM  CELLS 


57 


of  the  ovary  and  the  discharge  of  the  ovum  and  Kquor  folHcuh.     (For  a 
more  detailed  description  of  ovulation,  see  page  61.) 

The  Spermatozoon. — The  male  germ  cell  or  spermatozoon,  in  contrast 
with  the  egg-cell,  is  one  of  the  smallest  cells  in  the  human  body  and  is 
especially  adapted  for  locomotion  and  for  penetration  of  the  ovum. 
The  name  spermatozoon  reflects  the  once-current  belief  that  it  was  a 


Hem 


Connecting  'piece 


•Perfo7'ator 


)  Neck 


Tail'. 


End-piece  - 


7  Head-cap 


Anterior  centriole 
""Posterior  centriole 


Spiral  thread 

Mitocliondria  sheath 

Terminal  disc 
Axial  filament 


Fig.  41. — Human  spermatozoon.     Diagrammatic.     A,  surface  view;  B,  profile  view;  in 
C  the  head,  neck,  and  connecting  piece  are  more  highly  magnified.     (Howden-Gray.) 


parasite;  but  subsequent  studies  of  its  developmental  history   proved 
it  to  be  a  highly  specialized  cell. 

The  spermatozoon,  as  seen  in  the  seminal  fluid,  is  an  extremely  slender, 
delicate  cell  in  which  three  general  parts  can  be  recognized:  (1)  a  head, 
(2)  a  connecting  piece  and  (3)  a  tail  (Fig.  41).  The  head  on  side  view 
is  approximately  oval;  when  seen  on  edge  it  is  pear-shaped.  After  a 
basic  dye  it  is  seen  to  contain  the  nucleus  of  the  cell.    It  measures  about 


58  EMBRYOLOGY  AND  PHYSIOLOGY 

4.5  X  I  X  I  niicni.  The  coniiectiiig  piece  is  a  cylinder  al)out  six  micra 
in  len<;;th  and  slightly  thinner  than  the  head.  Some  investigators  recog- 
nize a  slight  constriction  or  neck  between  the  head  and  the  connecting 
piece.  The  latter  merges  with  the  long,  slender  tail  which  measures  from 
40  to  50  micra  in  length. 

Closer  analysis  of  the  spermatozoon  by  special  methods  of  technic 
shows  a  wealth  of  detail  in  the  three  parts  (Fig.  41),  The  head,  in  addi- 
tion to  containing  the  nucleus,  shows  also  a  mass  of  cytoplasm,  the  galea 
capitis,  terminating  in  a  fairly  sharp  edge,  the  perforator.  The  perforator 
probably  assists  the  spermatozoon  in  clinging  to,  or  liurrowing  its  way 
into,  the  ovum.  Immediately  behind  the  head  is  a  structure  known  as 
the  anterior  centriole  or  centrosome,  followed  by  a  disk  of  undiffer- 
entiated cytoplasm.  The  connecting  piece  proper  then  begins  in  the 
posterior  centriole  or  centrosome  and  extends  as  far  as  the  annulus  or 
end-ring.  The  connecting  piece  consists  of  a  central  filament,  a  delicate 
sheath  surrounding  the  latter,  then  a  spiral  filament  embedded  in  a 
homogeneous  substance,  and  on  the  outside  a  sheath  characterized  by  the 
presence  of  mitochondria.  The  central  filament  of  the  tail  is  a  continua- 
tion of  the  central  filament  of  the  connecting  piece  and  is  surrounded 
along  the  greater  part  of  its  course  by  a  sheath,  the  involucrum,  which 
is  probably  continuous  with  the  inner  sheath  of  the  connecting  piece. 
For  a  short  distance  from  its  end  the  central  filament  of  the  tail  is  naked, 
forming  the  end-piece. 

As  stated  previously,  spermatozoa  are  highly  motile  cells.  They  propel 
themselves  by  undulatory  movements  of  the  tail.  They  swim  against 
a  current,  even  dead  spermatozoa  floating  with  their  heads  in  a  similar 
direction,  the  explanation  for  which  is  probably  to  be  sought  in  their 
physical  structure.  This  adaptation  is  of  the  greatest  importance  for 
fertilization  because  it  determines  that  the  motile  cells  will  proceed 
against  the  outwardly  moving  current  set  up  by  the  cilia  of  the  uterus 
and  oviducts.  They  swim  at  a  rate  which  has  been  variously  estimated 
from  25  to  50  micra  per  second. 

Spermatozoa  possess  rather  remarkable  vitality.  The  motile  cells 
have  been  found  in  the  testis  of  a  criminal  three  days  after  execution. 
In  the  female  genital  passages  they  retain  their  activity  for  several  days 
or  even  weeks.  Weak  alkaline  solutions  cause  an  increase  in  their 
activity,  while  acids  destroy  them. 

Several  abnormal  forms  of  human  spermatozoa  have  been  observed, 
such  as  giants,  dwarfs,  forms  with  two  or  more  heads,  and  forms  with 
multiple  tails.  It  has  been  thought  that  the  atypical  forms  resulted 
from  general  weakening  of  the  body  by  illness  or  drugs. 

Development  of  the  Germ  Cells. — The  individual,  in  the  vast  majority 
of  animal  species,  l)egins  with  the  fertilized  ovum  or  spermovium  which 
is  the  result  of  the  union  of  a  mature  germ  cell  from  the  male  with  a 
mature  germ  cell  from  the  female.  The  spermovium  then  by  a  succes- 
sion of  cell  divisions  gives  rise  to  all  the  cells  of  the  organism.  These 
in  general,  as  mentioned  in  a  preceding  section,  can  be  divided  into 
somatic  cells,  which  play  the  dominant  part  in  the  economy  of  the 


THE  GERM  CELLS 


59 


individual  and  then  perish  without  descendant,  and  germ  cells  or  sex 
cells,  which  under  proper  conditions  serve  to  perpetuate  the  species. 
The  term  germ  plasm  is  frequently  used  to  designate  the  substance 
which,  as  the  chromatin  of  the  sex  cells,  passes  from  generation  to  genera- 
tion, constituting  the  hereditary  factor  and  carrying  on  the  line  of  the 
race. 

In  some  of  the  lower  animals  the  sex  cells  can  be  traced  directly  from 
the  first  division  of  the  spermovium  to  their  final  position  in  the  genital 
glands  of  the  adult.  Among  the  higher  animals,  on  the  other  hand, 
it  has  not  been  possible  to  follow  their  course  for  a  period  after  the  first 
division  of  the  spermovium,  but  they  are  first  distinguishable  in  a  modified 
part  of  the  peritoneum  when  the  embryo  has  attained  a  fairly  high 
degree  of  development.  At  this  time  they  are  spoken  of  as  primordial 
germ  cells,  but  exhibit  no  structures  which  characterize  them  as  either 
male  or  female.     A  little  later  in  development,  however  (fourth  or  fifth 


Female 


Frimordial  Germ  Cell 


Male 


Oorjonia  /  \  <  ^^ 

Oocytes  ftii^i^ik\ 


Oocyte  1st  Order 
Oocyte  2nd  Orde 
Ovum  (l) 


/       \ 
/          \ 

iij^ei-matogoma         /  \           ;  \ 

/;    /\     >'\    \\ 

STAGE 

I       OF 

GERMIN- 
ATION 

Spermatocytes^    *4hdii-^^ 
j 

1                      STAGE 

1          r   °^ 

1                   GROWTH 

Spermatocytes  1st  Ord.            ^           <- 

Spermatocytes  2nd  Ord.       4     \          V     ^"^ 

/ 1        1  \           [     MATUR- 

Spermatozoa  (4)                W    4    i    ^    J 

ATION 

Fig.  42. — Schema  of  comparative  descent  of  ovum  and  spermatozoa.  The  dotted  lines 
indicate  successive  cell  generation,  the  continuous  lines  connect  successive  stages  of  one  cell. 
(Modified  from  Boveri.) 

week  in  the  human  embryo),  they  differentiate  into  either  male  sex  cells 
(spermatogonia)  or  female  sex  cells  (oogonia)  according  as  the  embryo 
becomes  a  male  or  female.  From  the  time  of  differentiation  their  his- 
tories are  divergent. 

In  the  male  the  spermatogonia  continue  to  proliferate  in  the  testis 
during  the  sexual  activity  of  the  individual.  Some  of  the  spermatogonia 
increase  in  size  to  form  primary  spermatocytes.  Each  of  these  divides 
equally  to  form  two  secondary  spermatocytes,  each  of  which  in  turn 
divides  equally  to  form  two  spermatids.  The  spermatids  are  then 
transformed  directly  into  spermatozoa.  Each  primary  spermatocyte  thus 
gives  rise  to  four  spermatozoa,  and  furthermore,  during  the  last  two 
divisions  the  number  of  chromosomes  is  reduced  one-half  (see  Fig.  42). 

In  the  female  the  sex  cells  cease  proliferating  at  or  usually  before 
birth,  consequently  their  number  is  limited.  After  birth  the  oogonia  con- 
tinue to  increase  in  size,  and  to  a  much  greater  degree  than  the  sperma- 


60  EMBRYOLOGY  AND  PHYSIOLOGY 

togonia,  to  form  primary  oocytes.  Each  primary  oocyte  divides  miequally 
into  a  large  cell,  the  secondary  oocyte,  and  a  very  small  cell,  the  first 
polar  body.  Each  secondary  oocyte  divides  imequally  into  a  large  cell, 
the  mature  ovum,  and  a  very  small  cell,  the  second  polar  body.  Each 
primary  oocyte  thus  gi\'es  rise  to  one  large  functional  cell  and  two  small 
abortive  cells  (or  three  in  case  the  first  polar  body  divides).  During 
o6c^'te  divisions  the  number  of  chromosomes  is  reduced  one-half  (see 
Fig!  42). 

While  it  is  not  within  the  province  of  this  book  to  trace  the  entire 
history  of  the  germ  cells,  yet  it  is  important  to  describe  in  some  detail 
the  process  by  which  the  number  of  chromosomes  is  reduced  since  the 
reduction  occurs  in  preparation  for  the  union  of  the  male  with  the  female 
sex  cell,  a  condition  necessary  among  the  higher  animals  for  the  develop- 
ment of  a  new  individual. 

Maturation  of  the  Ovmn. — The  process  of  maturation,  or  reduction  of 
chromosomes,  has  not  been  observed  in  the  human  egg-cell.  Conse- 
quently we  must  draw^  upon  the  knowledge  gained  from  the  study  of 
lower  forms.  The  classical  objects  for  study  are  the  ova  of  Ascaris  megalo- 
cephala,  variety  bivalens  (a  round-worm  parasitic  in  the  intestine  of 
the  horse),  in  which  the  successive  stages  can  be  easily  followed. 

In  this  form,  in  which  the  somatic  number  of  chromosomes  is  four, 
the  process  is  initiated  in  the  primary  ooc^le  by  the  aggregation  of  the 
chromatin  elements  at  one  side  of  the  nucleus.  This  is  the  stage  of 
synapsis.  The  chromatin  then  becomes  arranged  in  a  convoluted  thread 
or  spireme.  The  spireme  splits  longitudinally  into  equal  halves  and  each 
half  in  turn  splits  longitudinally  into  equal  parts.  The  result  is  a  quad- 
ruple spireme,  which  then  segments,  that  is,  breaks  transversely,  into 
two  equal  portions.  Each  portion  is  thus  composed  of  four  rod-shaped 
pieces  of  chromatin  and  is  kno^^Ti  as  a  tetrad;  and  the  number  of  tetrads 
is  one-half  the  somatic  number  of  chromosomes. 

An  achromatic  spindle  next  forms,  as  in  ordinary  mitosis,  and  the  tetrads 
become  arranged  in  an  equatorial  plate.  Then  two  pieces  from  each 
tetrad  pass  out  into  a  small  mass  of  cytoplasm  which  becomes  separated 
from  the  main  mass  of  the  egg-cell  as  the  first  polar  body.  The  foiu- 
chromatin  rods  that  remain  in  the  cell,  now  the  secondary  oocj'te,  con- 
stitute two  dyads.  Without  the  return  of  the  chromatin  to  the  reticular 
condition,  the  second  polar  body  is  given  off  in  the  same  manner  as  the 
first,  one-half  of  each  dyad  remaining  in  the  large  egg-cell  which  is  now 
the  mature  ovum. 

The  result  of  the  maturation  process  is  thus  one  large  cell,  the  mature 
o\aun,  and  two  small  polar  bodies  (or  three  in  case  the  first  polar  body 
dix'ide.s).  The  mature  egg-cell  contains  one-half  the  number  of  chromo- 
somes and  is  prepared  to  unite  with  the  spermatozoon.  The  polar 
bodies  which  are  sometimes  spoken  of  as  abortive  ova,  disintegrate  and 
disappear. 

In  ascaris,  as  described  above,  the  reduction  in  the  number  of  chro- 
mosomes takes  place  with  tetrad  formation,  the  chromatin  rods  or  chro- 
mosomes in  the  tetrads  resulting  from  a  double  longitudinal  splitting 


THE  GERM  CELLS  61 

of  the  spireme.  While  the  scope  of  this  work  does  not  permit  a  detailed 
discussion  of  the  variations,  it  should  nevertheless  be  pointed  out  that 
in  most  animals  the  reduction  is  accomplished  without  tetrad  formation. 
The  differences  in  the  latter  case  are  found  in  the  behavior  of  the  chro- 
mosomes during  the  maturation  process.  The  spireme  segments  into 
a  number  of  rods  or  chromatin  masses  equal  to  one-half  the  somatic 
number  of  chromosomes.  In  some  cases  these  split  twice  longitudinally, 
but  the  second  split  occurs  some  time  after  the  first  so  that  no  tetrad 
figure  is  apparent.  In  other  cases  a  transverse  break  takes  the  place  of 
one  of  the  longitudinal  splits.  In  either  case,  however,  the  reduction 
to  one-half  the  somatic  number  of  chromosomes  is  effected. 


Fig.  43. — From  a  section  of  a  mature  Graafian  follicle  at  the  surface  of  the  ovary  of  a 
young  woman:  1,  stratum  granulosum;  2,  germ  hill  containing  an  oocyte  (ovarian  ovum); 
3,  same  as  i;  ^,  germinal  epithelium;  5,  tunica  albuginea;  6,  theca  folliculi,  internal  vascular 
layer;  7,  theca  folliculi,  external  fibrous  layer;  8,  same  as  1.     (Kollmann's  Atlas.) 

Ovulation. — By  ovulation  is  meant  the  periodic  discharge  of  the  ovum 
from  the  ovary.  The  mature  Graafian  follicle  (p.  55)  ruptures  at  the 
surface  of  the  ovary  through  the  thinned  portion  of  its  own  wall  and 
of  the  tunica  albuginea  (Fig.  43).  The  cause  of  the  rupture  is  possibly 
twofold:  increased  pressure  within  the  ovary  due  to  increased  vascular- 
ity of  the  organ  and  increased  amount  of  liquor  folliculi.  The  ovum  is 
discharged  into  the  peritoneal  cavity  in  the  immediate  vicinity  of  the 
fimbriated  end  of  the  Fallopian  tube  whence  it  normally  passes  into  the 
tube  and  so  to  the  uterus.  The  liquor  follicuH  and  some  of  the  follicular 
cells,  especially  those  of  the  corona  radiata,  escape  with  the  ovum. 

The  Corpus  Luteum.— Following  the  discharge  of  the  contents  of  the 
Graafian  follicle  the  walls  collapse  and  a  considerable  quantity  of  blood 


62 


EMBRYOLOGY  AND  PHYSIOLOGY 


escapes  into  the  central  cavity  from  ruptured  vessels  of  the  theca.  The 
follicle  becomes  a  closed  vesicle  again  through  closure  of  the  ruj)tured 
wall,  and,  with  the  blood-clot  in  the  interior,  is  called  the  corpus  hemor- 
rhagicum.  This  represents  the  first  stage  in  the  development  of  the 
corpus  luteinn.  Gradually  the  blood-clot  is  replaced  by  lar^e,  closely 
packed  cells  containing  yellow  granules  (whence  the  name  corpus  luteum, 
although  in  other  mammals  the  colors  are  different,  being  brick-red 
in  the  mouse  and  pale  brown  in  the  sheep).  These  granules  are  of  a 
fatty  nature.  There  is  difference  of  opinion  as  to  the  origin  of  the  lutein 
(yellow)  cells,  some  believing  that  the>'  arise  from  the  epithelium  forming 
the  stratum  granulosum  of  the  follicle,  others  holding  that  they  come 
from  the  connective-tissue  cells  of  the  theca  folliculi  (Figs.  44  and  45). 


Fig.  44. — An  ovary  of  a  girl  nineteen  years  old.  The  organ  has  been  cut  open  longitudin- 
ally and  shows  a  young  corpus  luteum  and  a  number  of  Graafian  follicles.  The  lower  half 
of  the  figure  shows  a  remnant  of  the  corpus  homorrhagicuni.      (Kollmann's  Atlas.) 


By  degeneration  and  subsequent  absorption  the  lutein  cells  are  dimin- 
ished in  number  and  the  corpus  luteum  is  gradualh'  replaced  by  connec- 
tive tissue  which  grows  in  from  all  sides.  Eventually  there  remains  only 
a  small  area  of  scar  tissue  to  mark  the  position  of  the  original  Graafian 
follicle. 

The  behaA'ior  of  the  corpus  luteum,  but  not  the  structure,  is  influenced 
materially  by  the  fate  of  the  ovum  from  that  particular  follicle.  If  the 
ovum  is  not  fertilized  and  consequently  pregnancy  does  not  follow,  the 
corpus  luteum  reaches  its  maximimi  within  two  or  three  weeks  and  then 
undergoes  the  characteristic  regressi\'e  changes.  Under  these  conditions 
it  is  known  as  a  false  corpus  luteum  (corpus  luteum  spurium).  In  case 
fertilization  occurs  and  pregnancy  supervenes,  the  life  history  of  the 
corpus  luteum  is  much  prolonged.  It  becomes  much  larger  than  in  cases 
of  non-pregnancy  and   reaches  its  maximum   about  the  sixth  month 


THE  GERM  CELLS 


63 


of  gestation.  After  that  it  undergoes  the  usual  regressive  changes. 
Although  called  by  older  writers  the  true  corpus  luteum  (corpus  luteum 
verum),  it  is  now  generally  agreed  that,  apart  from  size  and  longer  his- 
tory, there  is  no  essential  histological  difference  between  it  and  the 
so-called  false  corpus  luteum. 

Maturation  of  the  Spermatozoon. — The  reduction  of  chromosomes  in 
the  male  germ  cell  of  ascaris  is  accomplished  in  the  same  manner  as  in 
that  of  the  female.    The  behavior  of  the  cytoplasm  is  different,  however, 


Point  of  rupture 


>^^^     Tunica  _ 
""VS^if^         albuginea 


Remnant 

of  corpus 

hemorrhagioum 


Lutein  cells 
Theca  folliculi 


Theca  folliculi 


Bloodvessels  of 
,.,  .,  -^  ^  — ,-  -,.,_^         .^  ,  ^  ^  '^  -r,, theca 

Fig.  45. — From  a  section  of  a  human  ovary,  showing  portion  of  a  well-advanced  corpus 
luteum  (eight  to  ten  daj-s).      (Kollmann's  Atlas,  after  Kreis.) 


in  that  each  primary  and  secondary  spermatocyte  di^"ides  into  equal 
parts.  The  result,  therefore,  is  four  equal  cells,  each  containing  one-half 
the  somatic  number  of  chromosomes. 

As  regards  the  maturation  of  the  human  male  sex  cell,  a  most  inter- 
esting and  important  piece  of  work  has  been  done  recently  by  Guyer. 
This  investigator  has  been  able  not  only  to  follow  the  successive 
generations  of  sex  cells  in  the  testis,  but  also  to  estimate  the  number 
of  chromosomes  in  each  generation. 

In  all  spermatogonia  in  which  a  definite  count  can  be  made  during  the 


64  EMBRYOLOGY  AND   PHYSIOLOGY 

mitotic  process  twenty-two  chromosomes  occur.  In  a  few  cases  two  of 
the  chromosomes  Ue  apart  from  the  main  mass,  surrounded  by  a  clear 
area  of  cytoplasm.  These  two  are  considered  "accessory"  chromosomes. 
In  preparation  for  division  in  the  primary  spermatocyte  twelve  chromo- 
somes appear.  Of  these,  two  are  the  "accessories"  and  the  other  ten 
represent  double  or  bivalent  chromosomes  which  have  resulted  from 
pairing  of  the  twenty  that  constituted  the  main  mass  of  chromosomes  in 
the  spermatogonium.  In  division  of  the  primary  spermatocyte  the  two 
"accessory"  chromosomes  pass  undivided  to  one  pole  of  the  spindle  while 
the  ten  double  chromosomes  divide  and  ten  single  ones  go  to  each 
daughter  cell.  Of  the  two  secondary  spermatocytes  arising  from  the 
division  of  the  primary,  one  receives  ten  single  chromosomes  and  the 
other  receives  ten  single  and  two  "accessory"  chromosomes. 

The  ten  single  chromosomes  that  pass  to  one  secondary  spermatoc}i:e 
again  unite  in  pairs,  resulting  in  five  double  or  bivalent  chromosomes. 
\Vhen  this  spermatocyte  divides  each  of  the  two  daughter  cells  receives 
five  double  chromosomes  which  are  equivalent  to  ten  single  chromosomes. 
The  ten  single  chromosomes  that  pass  to  the  other  secondary  sperma- 
toc^iie  behave  in  the  same  manner  as  described  above;  but  each  of  the 
"accessories"  also  divides  like  an  ordinary  chromosome,  so  that  each 
spermatid  in  this  case  receives  not  only  five  double  but  also  two  "  acces- 
sory" chromosomes,  thus  making  a  total  of  seven.  The  five  double  are 
of  course  equal  to  ten  single  chromosomes. 

Of  the  total  number  of  spermatids,  then,  half  have  received  ten  chro- 
mosomes and  half  have  received  twelve  (ten  plus  two  "accessory"). 
Since  the  spermatids  are  transformed  directly  into  spermatozoa,  it 
follows  that  there  are  two  classes  of  the  latter,  differing  as  to  whether 
they  do  or  do  not  contain  the  two  "accessory"  chromosomes. 

It  is  not  improbable  that  the  "accessory"  chromosomes  in  man  are 
analogous  to  similar  structures  found  in  certain  other  vertebrates  and 
in  many  species  of  insects,  myriapods  and  arachnids.  In  these  lower 
forms  it  has  been  found  also  that  not  only  do  some  of  the  male  sex  cells 
possess  additional  or  "accessory"  chromosomes  but  that  the  somatic 
cells  of  the  female  are  characterized  by  the  extra  number  of  chromo- 
somes. On  the  assumption  that  in  the  human  species  the  number  of 
chromosomes  in  the  female  sex  cell  is  twenty-four,  or  twelve  in  the 
mature  ovum,  the  fertilization  of  the  ovum  by  a  spermatozoon  possessing 
ten  chromosomes  would  result  in  a  male,  with  twenty-two  chromosomes; 
on  the  other  hand  the  fertilization  of  an  ovum  by  a  spermatozoon  with 
twelve  (ten  single  plus  two  "accessory")  chromosomes  would  result 
in  a  female,  with  twenty-four. 

The  results  of  some  other  investigations  are  at  variance  with  the 
above  account  as  to  the  number  of  cliromosomes  in  the  human  being. 
Wieman,  for  instance,  has  counted  thirty-three,  thirty-four  and  thirty- 
eight  chromosomes  in  somatic  cells  during  the  cell-di\'ision  in  the  embryo. 
These  differences  remain  to  be  explained. 

The  transformation  of  the  spermatid  into  the  spermatozoon,  referred 
to  above,  is  the  expression  of  the  change  which  a  relatively  non-motile 


FERTILIZATION  65 

cell  undergoes  to  become  adapted  to  a  function  requiring  a  high  degree 
of  motility.  The  change  is  essentially  one  of  form  (cytomorphosis)  in 
which  most  of  the  cytoplasm  is  drawn  out  into  a  long,  slender  flagellum 
or  organ  of  locomotion.  The  chromatin  of  the  spermatid  returns  to  the 
reticular  condition  and  a  nuclear  membrane  appears  around  it.  The 
centrosome,  at  one  side  of  the  cell,  divides  into  a  diplosome  and  the 
nucleus  moves  to  the  opposite  side.  The  nucleus  becomes  more  compact, 
and,  together  with  a  small  amount  of  cytoplasm,  is  destined  to  become 
the  head  of  the  spermatozoon.  The  part  of  the  diplosome  nearer  the 
nucleus  becomes  disk-shaped,  and,  retaining  this  position,  becomes  the 
anterior  centrosome  or  end-knob.  From  the  other  part  of  the  diplosome 
a  slender  filament  grows  out,  extending  beyond  the  boundary  of  the 
cytoplasm.  Along  this  filament  most  of  the  cytoplasm  becomes  drawn 
out,  the  former  constituting  the  axial  filament  and  the  latter  the  sheath 
or  involucrum  of  the  tail.  The  body  from  which  the  filament  grew  also 
becomes  disk-shaped  and  forms  the  posterior  centrosome  or  end-knob. 
Originating  from  it  also  is  a  ring  which  apparently  slips  along  the  filament 
for  a  short  distance  and,  as  the  end-ring,  marks  the  posterior  end  of  the 
connecting  piece.  Certain  granules  in  the  cytoplasm  (mitochondria) 
probably  unite  to  form  the  spiral  filament  of  the  connecting  piece  while 
others  remain  as  a  characteristic  feature  of  the  mitochondrial  sheath. 

As  regards  the  number  of  germ  cells  produced,  it  has  been  estimated 
that  about  36,000  primary  oocytes  develop  in  each  ovary,  of  which  200 
become  ripe.  It  has  been  calculated  that  the  average  ejaculate  contains 
about  200,000,000  spermatozoa,  and  that  during  his  life  a  man  would 
produce  340,000,000,000.  These  estimates  make  it  appear  that  for  each 
mature  ovum  850,000,000  spermatozoa  are  produced. 

FERTILIZATION. 

In  sexual  reproduction  the  starting-point  of  the  new  individual  is  the 
single  cell  resulting  from  the  union  of  the  mature  germ  cell  of  the  male 
with  the  mature  germ  cell  of  the  female.  This  union  is  known  as  fer- 
tilization and  the  resulting  cell  as  the  fertilized  ovum,  or  spermovium. 
Nothing  is  known  concerning  this  process  in  the  human  subject,  but  the 
presumption  is  that  it  occurs  in  essentially  the  same  manner  as  in  other 
mammals. 

Broadly  speaking,  fertilization  includes  all  the  phenomena  from  the 
time  the  spermatozoon  enters  the  egg  until  the  two  nuclei  (often  called 
the  male  pronucleus  and  female  pronucleus)  unite.  It  may  therefore 
be  conveniently  divided  into  three  phases:  (1)  the  entrance  of  the  sper- 
matozoon, (2)  its  progress  to  the  centre  of  the  egg  cytoplasm  and  (3) 
zygosis  of  the  two  pronuclei. 

The  approach  of  the  spermatozoon  to  the  ovum,  apart  from  the  swun- 
ming  movements  of  the  former  through  the  genital  passages  of  the 
female,  probably  depends  upon  a  positive  chemotaxis.  This  attraction, 
in  the  majority  of  cases,  is  specific  for  the  germ  cells  of  a  given  species, 
that  is,  there  is  a  positive  chemotaxis  between  ova  and  spermatozoa  of  ■ 
5 


66 


EMBRYOLOGY  AXD  PHYSIOLOGY 


the  same  species  onlv.  In  some  animals  the  ovum  sends  out  a  sma  1 
cytoplasmic  projection  or  attraction  cone,  analogous  to  a  i)seudopod, 
to  meet  the  sperm  cell  (Fig.  4(5).  Some  ova  that  possess  a  vitelline  mem- 
brane are  permeable  at  all  points,  while  others  are  permeable  onl>-  at  one 


Zona  pellucida 

Nucleus 
-—  SDcrmaiozoon 


--^--A-— Cytopl 


asm 


Female 
pronucleus 


Head  of 


j^  —spermatozoon 
I      with  centrosome 


Female  pronucleus 


Male  pronucleus 


-Centrosome 


Male  pronucleus 
Female  pronucleus 


Chromosomes  of 
A-"  icnialc  pronucleus 


■Chromosomes  of 
male  pronucleus 

'Centrosome 


Chromosome  from 
female  pronucleus 


ixmim 


---Centrosome 


Fig    46 -Diagram  of  fertilization  of  the  ONtim.     (The  somatic  number  of  chromosomes 
is  4.)     (Boveri,  Bohm  and  von  Davidoff.) 

point  where  there  is  a  minute  opening,  or  micropxle,  in  the  membrane. 
In  mammals  normallv  only  one  sperm  cell  enters  the  egg.  Should  more 
than  one  enter,  as  in  pathological  pol>spermy,  the  result  is  an  irregular 
formation  of  mitotic  figures  and  the  early  <leath  of  the  egg.  As  a  rule 
onlv  the  head  and  a  portion  ..f  the  cnnecting  piece  of  the  spermatozoon 


CLEAVAGE  AND  FORMATION  OF   THE  GERM  LAYERS  67 

actually  penetrate  the  egg-cytoplasm,  and  the  tail,  having  performed  its 
function,  is  left  on  the  outside.  Thus  the  nucleus  and  centrosome,  the 
two  elements  essential  to  further  development,  are  carried  into  the  egg 
(Fig.  46).  After  the  entrance  of  the  sperm-cell  requisite  for  fertilization, 
all  others  are  excluded  (except  in  certain  animals  where  several  enter 
normally  but  only  one  unites  with  the  egg-nucleus). 

The  sperm  nucleus  and  centrosome,  now  within  the  egg,  move  to  the 
centre  of  the  cytoplasm,  the  centrosome  usually  in  advance  of  the  nucleus 
(Fig.  46).  After  the  last  maturation  division  of  the  ovum  the  female 
pronucleus  also  moves  toward  the  centre  of  the  cell  and  eventually 
takes  a  position  beside  the  male  pronucleus.  The  centrosome  lies  between 
the  two  (Fig.  46). 

Zygosis  does  not  signify  the  literal  fusion  of  the  two  pronuclei  to  form 
a  single  nucleus,  but  the  behavior  of  the  cliromatin  preparatory  to  the 
first  cell  division.  The  centriole  divides  and  a  spindle  is  formed  between 
the  two  pronuclei.  The  chromatin  in  the  pronuclei  becomes  arranged 
in  chromosome  form,  each  pronucleus  giving  rise  to  one-half  the  somatic 
number.  The  chromosomes  then  form  a  common  equatorial  plate  in 
the  spindle  (Fig.  46) .  The  equatorial  plate  therefore  contains  the  somatic 
number  of  chromosomes,  as  in  ordinary  mitosis.  Each  chromosome 
splits  longitudinally  into  two  equal  parts,  of  which  one  part  passes  to 
one  pole  of  the  spindle  and  the  other  to  the  opposite  pole.  It  follows 
that  the  two  daughter  nuclei  resulting  from  the  first  division  of  the 
sperm-ovium  receive  equal  numbers  of  maternal  and  paternal  chromo- 
somes (Fig.  46). 

The  point  where  fertilization  normally  occurs  in  the  female  genital 
tract  is  not  definitely  known.  In  the  lower  mammals  it  takes  place  in 
the  Fallopian  tube,  or  oviduct,  and  the  general  opinion  is  that  in  the 
human  subject  also  it  occurs  in  the  tube,  probably  in  the  outer  third. 
Not  only  does  the  occurrence  of  tubal  pregnancies  certify  that  sperma- 
tozoa enter  the  Fallopian  tube,  but  they  have  also  been  observed  there. 
In  rare  cases  they  may  pass  all  the  way  through  the  tube  and  fertilize 
the  ovum  on  the  surface  of  the  ovary  or  even  in  the  Graafian  follicle, 
resulting  in  ovarian  pregnancy. 

'       CLEAVAGE   AND   FORMATION    OF   THE    GERM   LAYERS. 

Cleavage  or  segmentation  constitutes  a  series  of  cell  divisions  fol- 
lowing fertilization  of  the  ovum,  the  phenomena  in  general  being  iden- 
tical with  those  of  ordinary  mitosis.  The  sperm-ovium  divides  into  two 
cells,  each  of  these  in  turn  divides,  and  so  on,  division  succeeding  division 
until  a  multicellular  mass  is  formed  which,  from  its  resemblance  to  a 
mulberry,  has  been  called  a  morula.  The  proliferation  of  cells  from  the 
sperm-ovium  is  therefore  the  first  of  the  series  of  processes  in  the  develop- 
ment of  a  new  individual. 

The  details  of  cleavage  have  been  studied  for  the  most  part  in  the 
lower  animals.  Observations  have  also  been  made  on  mammalian  forms, 
particularly  the  mouse,  rabbit,  and  bat.     In  the  mouse  Sobotta  found 


68 


EMBRYOLOGY  AXD  PHYSIOLOGY 


that  the  fertihzed  ovum  divided  into  two  approximately  equal  cells, 
that  the  second  cleavage  was  completed  in  one  of  these  before  the  other 
began  to  di\ade,  thus  resulting  in  a  three-cell  stage,  and  that  then 
cleavage  continued  irregularly  (Fig.   47,  a,  h,  c,  d,  e).     Fig.   48,   from 


©\^-. 


d  e 

Fig.  47. — Five  stages  in  cleavage  of  the  o\Tim  of  the  mouse:  a,  the  first  division  has 
resulted  in  two  subequal  cells;  a  polar  body  is  shown  at  upper  side  of  figure;  h,  section  of  a 
four-cell  stage,  only  three  cells  showing  in  the  figure;  c,  eight-cell  stage,  five  cells  showing  in 
the  section;  d,  twelve-cell  stage,  seven  cells  showing  in  the  section;  e,  twenty-cell  stage,  ^ath 
marked  difference  in  size  and  structure  of  cells.     (Sobotta.) 


Fig.  48. — From  a  section  of  the  morula  of 
the  bat.     (Van  Beneden.) 


Fig.  49.  • —  Ovum  of  a  monkey  in 
segmentation,  from  the  tube  of  Maca- 
cus  nemestrinus.     (Selenka.) 


Van  Beneden's  w^ork,  shows  a  section  of  the  morula  of  the  bat.  Fig.  49 
shows  a  four-cell  stage  of  the  ovum  of  a  monkey  (Macacus  nemestrinus), 
which  is  the  onl\'  primate  ovum  in  the  cleavage  stage  known  at  the 
present  time,  and  was  found  at  about  the  middle  of  the  oviduct. 


CLEAVAGE  AND  FORMATION  OF  THE  GERM  LAYERS 


69 


'J  7 


■^J 


■^1 


'h 


io 


iVX^ 


In  mammals  whose  ova  contain  a  relatively  small  amount  of  yolk 
(deutoplasm)  the  cells  of  the  morula  are  similar  in  appearance  and 
approximately  equal  in  size.  The  eggs  of  other  vertebrates  exhibit 
great  differences  in  this  respect.  In  amphibians,  for  example,  while 
the  whole  egg  divides  the  cells  at  one  pole  remain  larger  than  at  the 
opposite  pole  omng  to  the  fact  that  the 
yolk,   which   is  accumulated   at  one  pole,  ,-'"''^^^%5v. 

retards  the  process  of  cell  division.    In  the  ^ 

eggs  of  birds  and  reptiles,  which  contain  a 
very  great  amount  of  yolk  and  the  cyto- 
plasm is  almost  wholly  confined  within  a 
small  area  at  one  pole  of  the  egg,  cleavage 
goes  on  only  in  the  cytoplasm  and  the 
result  is  merely  a  disk  of  cells  lying  upon 
the  large  unsegmented  mass  of  yolk.  The 
presence  of  yolk  therefore  not  only  modi- 
fies the  cleavage  process  but  has  a  far- 
reaching  influence  upon  later  development, 
and  the  mammalian  egg-cell,  while  it  con- 
tains but  a  small  amount  of  yolk,  develops 
after  cleavage  in  many  respects  as  if  it  were 
laden  with  the  nutritive  substance.  This  is  usually  considered  as  a  point 
of  evidence  in  favor  of  the  view  that  mammals  have  descended  from 
animals  whose  ova  possessed  large  quantities  of  yolk. 

The  first  visible  differentiation  of  cells  in  the  mammalian  morula 
occurs  in  the  superficial  layer.  The  cells  of  this  layer  acquire  a  more 
regular  shape,  and  a- section  of  the  morula  at  this  stage  presents  a  picture 
of  a  covering  layer  surrounding  a  central  mass  of  irregular  (polygonal) 


^  ^K( 


-J/ 


Fig.  50. — From  a  section  of  a 
later  stage  of  the  morula  than  in 
Fig.  49,  showing  differentiation  of 
the  outer  layer  of  cells.  (Van 
Beneden.) 


l-za^^^tt^^'^^^ 


"_/ 


Fig.  51. — From  a  section  of  the  devel- 
oping ovum  of  a  bat,  showing  vacuolation 
of  the  inner  cells.      (Van  Beneden.) 


Fig.  52. — From  a  section  of  a  later  stage 
than  Fig.  51,  showing  outer  layer  (tropho- 
derm)  and  inner  cell  mass.    (Van  Beneden.) 


cells  (Fig.  50).  The  morula  is  then  transformed  into  a  vesicle  by  the 
vacuolation  of  most  of  the  inner  cells  and  the  confluence  of  these  vacuoles 
to  form  a  common  cavity.  The  few  inner  cells  that  do  not  become 
vacuolated  remain  attached  in  a  group  to  the  outer  layer.  The  mam- 
malian ovum  at  this  stage  thus  consists  of  two  groups  of  cells:  an  outer 


70 


EMBRYOLOGY  AXD  PHYSIOLOGY 


group  or  layer  of  cuboidal  cells  to  which  the  name  tro})hotlerni  (tropho- 
blast)  is  given  and  an  inner  group  which  has  received  the  name  inner 
cell  mass. 

The  vacuolation  of  the  inner  cells  of  the  morula  probai)ly  represents 
a  late  and  abortiv^e  attempt  at  yolk  formation,  and  the  cavity  formed 
by  the  coalescence  of  the  \'acuoles  corresponds  to  the  yolk  mass.  The 
inner  mass  is  comparable  with  the  disk  of  cells  that  rests  upon  the  yolk 
in  eggs  of  the  lower  vertebrates  (reptiles  and  birds).  In  man  the  nutri- 
tive yolk  is  unnecessary  since  the  attachment  of  the  developing  ovum 
to  the  wall  of  the  uterus  provides  for  direct  parental  nutrition.  In  the 
process  dividing  the  cells  of  the  morula  into  an  inner  cell  mass  and 
trophoderm  is  seen  the  earliest  differentiation  into  cells  which  will,  on 
the  one  hand,  give  rise  to  the  embryo  proper  and  on  the  other  hand 
engage  in  the  development  of  certain  accessory  or  extra-embryonic  struct- 
ures, the  fetal  membranes  (Fig.  51  and  52). 


W<0^ 


Fig.  53. — From  a  section  of  the  blastodermic  vesicle  of  a  bat,  shownng  formation  of  entoderm. 

(Van  Beneden.) 

The  next  step  in  mammalian  development,  as  exemplified  by  the  ovum 
of  the  bat,  is  the  differentiation  and  splitting  off  of  the  deeper  cells  of 
the  inner  cell  mass.  These  cells,  as  a  single  layer,  then  gradually  extend 
in  all  directions  on  the  inner  surface  of  the  trophoderm  until  they  line 
the  entire  vesicle.  This  new  layer  of  cells  is  the  entoderm  (Fig.  53). 
While  the  entoderm  is  developing  the  superficial  cells  of  the  inner  cell 
mass  become  vacuolated  (Fig.  54),  and  the  vacuoles  coalesce  to  form  a 
cavity  between  the  overlying  trophoderm  and  the  deeper  cells  of  the 
inner  cell  mass.  This  cavity  is  the  amniotic  cavity  (Fig.  55).  Its  roof 
is  trophoderm  and  its  floor  is  formed  by  the  remaining  cells  of  the  inner 
cell  mass  which  are  now  arranged  in  a  regular  layer.  This  lies  in  contact 
with  the  entoderm  and  constitutes  the  embryonic  ectoderm,  the  two 
layers  together  in  this  region  forming  the  embryonic  disk. 

The  ovum  at  this  stage  is  thus  a  vesicle,  known  as  the  blastodermic 
vesicle,  with  a  small  amniotic  cavit>-  at  one  pole  and  a  much  larger  yolk 
cavity  extending  to  the  opposite  pole,  the  cavities  being  separated  by 
the  embryonic  disk.     The  amniotic  cavity  is  lined  in  part   (the  roof) 


CLEAVAGE  AND  FORMATION  OF   THE  GERM  LAYERS 


71 


by  trophoderm,  in  part  (the  floor)  by  embryonic  ectoderm.  The  yolk 
cavity  is  lined  by  entoderm.  The  vesicle  wall  is  composed  of  trophoderm 
and,  around  the  yolk  cavity,  also  of  entoderm. 

The  two-layered  stage  of  the  embryonic  disk  in  this  case  is  arrived 
at  by  the  simple  process  of  the  splitting  off  (delamination)  and  dift'eren- 
tiation  of  the  deeper  cells  of  the  inner  cell  mass.  To  attempt  to  homol- 
ogize  this  process  with  the  process  of  invagination  by  which  the  two 
primary  germ   layers   (ectoderm  and  entoderm)   are  formed  in  lower 


Fig.  54.- 


-From  a  section  of  the  blastodermic  vesicle  of  a  bat,  showing  vacuolation  of  the 
inner  cell  mass  to  form  the  amniotic  cavity.     (Van  Beneden.) 


mammals  and  other  vertebrates  and  in  the  invertebrates  would  neces- 
sitate a  much  longer  and  more  detailed  description  than  the  scope  of 
this  book  justifies.  The  student  is  therefore  referred  to  the  text-books 
of  embryology. . 

Soon  after  the  completion  of  the  two-layered  stage  of  the  blastodermic 
vesicle  there  appears  a  thickening  of  the  ectoderm  over  a  small  area  in 
the  embryonic  disk.  This  thickening  is  known  as  the  embryonic  shield 
(Fig.  56),  and  occurs  in  all  mammals  thus  far  studied.    On  surface  view 


Fig.  .55.- 


-Fiom  a  section  of  the  blastodermic  vesicle  of  a  bat,  showing  the  amniotic  cavity. 
Cf.  Fig.  54.      (Van  Beneden.) 


there  next  appears,  in  the  dog,  for  example,  a  small  more  opaque  spot 
near  the  centre  of  the  embryonic  shield.  This  is  the  primitive  node  (Fig. 
56).  Then  a  narrow  opaque  band,  extending  from  the  node  to  the  border 
of  the  shield,  develops  and  is  known  as  the  primitive  streak  (Fig.  56). 
A  slight  furrow  in  the  ectoderm  in  the  line  of  the  primitive  streak  is 
spoken  of  as  the  primitive  groove. 

A  section  taken  vertical  to  the  surface  of  the  embryonic  shield  and  at 
right  angles  to  the  primitive  streak  shows  that  the  ectoderm  and  ento- 


72  EMBRYOLOGY  AND  PHYSIOLOGY 

derm  are  fused  with  an  intermediate  layer  along  the  line  of  the  streak 
and  that  the  intermediate  layer  extends  laterally  for  some  distance 
as  a  band  of  cells  apposed  to  the  entoderm.  This  new  layer  is  the  meso- 
derm (Fig.  57). 


Fig.  56. — Surface  ^-iew  of  the  embryonic  shield  of  the  blastodermic  vesicle  of  a  dog 
thirteen  to  fifteen  days  old — precise  age  unknown:  Sh.,  embrj-onic  shield;  Kn.,  Hensen's 
knot;  p.s.,  primitive  streak.     100  diameters.     (From  Minot,  after  Bonnet.) 

In  the  case  under  consideration  the  primitive  streak  represents  a  line 
of  fusion  of  the  three  germ  layers.  Its  real  significance  can  be  appre- 
ciated only  when  its  history  is  traced  back  through  the  series  of  lower 
animals.  In  general  it  can  be  compared  with  the  blastopore,  although 
perhaps  cannot  be  homologized  directly  with  it.     The  blastopore  in 


Ectoderm 


Jli'"'  ,V         t     ft***^!/*^*-*.-^     Mesoderm 


Entoderm  Primitive 

streak 

Fig.  57. — From  a  transverse  section  through  the  primitive  streak  and  groove  of  the  embry- 
onic disk  of  a  dog  (shown  in  Fig.  56.)     (Bonnet.) 

lower  forms  is  the  opening  into  the  interior  (archenteron,  primitive  gut) 
of  the  developing  organism  at  the  point  where  invagination  occurs  to 
give  rise  to  the  entoderm.  Since  in  mammals  the  entoderm  arises  by 
delamination  of  certain  cells  of  the  inner  cell  mass  and  not  by  invagina- 


CLEAVAGE  AND  FORMATION  OF   THE  GERM  LAYERS  73 

tion,  conditions  in  the  region  that  would  otherwise  have  been  occupied 
by  the  blastopore  are  different.  The  difference  is  expressed  in  the  forma- 
tion of  the  primitive  streak. 

As  regards  the  origin  of  the  mesoderm  in  mammals,  and  even  in  birds 
and  reptiles,  there  is  much  difference  of  opinion.  That  it  appears  along 
the  line  of  the  primitive  streak  is  undisputed,  and  that  it  grows  out 
from  this  region  for  some  distance  between  ectoderm  and  entoderm  is 
practically  certain  (Fig.  57),  but  whether  it  arises  from  ectoderm  or 
entoderm  has  not  yet  been  determined.  In  the  lower  vertebrates  and 
Amphioxus  it  obviously  originates  from  entoderm. 

In  addition  to  that  arising  in  the  region  of  the  primitive  streak  there 
is  also  in  mammals  a  considerable  amount  of  mesoderm  which  appears 
in  the  wall  of  the  blastodermic  vesicle,  between  the  trophoderm  and  the 
entoderm  lining  the  yolk  cavity.  There  is  likewise  some  doubt  as  to  the 
origin  of  this  portion  of  mesoderm,  but  the  view  best  supported  by 
evidence  is  that  it  arises  in  loco  by  differentiation  and  splitting  off 
(delamination)  from  the  entoderm,  as  it  does  around  the  yolk  sac  in 
reptiles  and  birds  and  around  the  yolk-laden  entoderm  in  the  frog. 

Through  the  formation  of  mesoderm  in  the  region  of  the  primitive 
streak  and  around  the  yolk  cavity,  both  the  embryonic  disk  and  the 
wall  of  the  yolk  cavity  become  three-layered.  Subsequently  the  roof 
of  the  amniotic  cavity  also  acquires  a  layer  of  mesoderm  which  separates 
the  trophoderm  on  the  outside  from  a  layer  of  ectoderm  on  the  inside, 
the  latter  being  continuous  with  the  ectoderm  of  the  embryonic  disk. 

At  this  stage,  therefore,  the  developing  organism  is  approximately 
spherical  in  shape  and  consists  of  a  triple-layered  wall  surrounding  a 
double  cavity.  The  smaller  amniotic  cavity  is  lined  with  ectoderm  and 
the  larger  yolk  cavity  with  entoderm,  the  two  cavities  being  separated 
by  the  embryonic  disk.  The  disk  is  composed  of  ectoderm,  mesoderm 
and  entoderm,  the  three  layers  being  fused  in  the  primitive  streak. 
The  trophoderm,  as  the  outer  layer  of  the  wall,  forms  a  complete  covering 
for  the  vesicle.  The  mesoderm  of  the  wall  is  also  a  complete  layer  and 
is  continuous  with  that  of  the  embryonic  disk.  All  three  layers  are 
everywhere  in  close  apposition.  The  disk  alone  will  give  rise  to  the 
body  of  the  embryo  and  the  other  structures  to  embryonic  appendages 
which  serve  to  protect  and  bring  the  embryo  into  proper  nutritional 
relations  with  the  maternal  tissues. 

The  Germ  Layers  in  Man. — While  there  are  no  observations  on  the 
segmentation  of  the  ovum,  the  first  differentiation  of  cells  or  the  origin 
of  the  germ  layers  in  the  human  subject,  it  is  not  unreasonable  to  assume 
that  the  foregoing  account  of  the  early  processes  of  development,  which 
applies  to  mammals  in  general,  would  apply  also  in  the  main  outline  to 
man.  In  the  youngest  human  ovum  thus  far  known,  which  has  been 
described  by  Bryce  and  Teacher  and  the  age  of  which  reckoned  at  thir- 
teen to  fourteen  days,  all  three  germ  layers  are  already  present  (Fig.  72). 
The  ovum  as  a  whole  comprises  an  outer  layer  of  trophoderm  surround- 
ing a  relatively  large  amount  of  mesoderm  in  which  two  cavities  are 
situated.    This  stage  is  thus  comparable  with  the  three-layered  vesicle 


74  EMBRYOLOGY  AM)   PHYSIOLOGY 

;iinl  einlirx oiiic  disk  of  niaininals  (Icxrilxd  in  tlu'  prt'cediiifj;  para,ura])h, 
although  there  are  some  well-marked  difi'ereiiees. 

The  trophoderm,  disregarding;  the  irregular  projections  from  the 
surface  which  will  be  considered  in  connection  with  the  fetal  membranes, 
forms  a  complete  covering  layer.  The  two  cavities  within  the  ovum  are 
relatively  small,  the  smaller  of  the  two  being  regarded  as  the  yolk 
cavity  lined  with  ento<^lerm  and  the  larger  as  the  amniotic  cavity  lined 
by  ectoderm.  One  of  the  most  striking  features  is  the  large  amount  of 
mesoderm,  which  is  here  a  delicate,  loosely  arranged  tissue  resembling 
mesenchyme.  The  embryonic  disk  is  represented  merely  by  a  small 
portion  of  ectoderm  and  entoderm  in  the  wall  of  the  amniotic  and  yolk 
cavities  respecti^•ely,  together  with  the  mesoderm  that  lies  between. 
The  roof  of  the  amniotic  cavity  is  separated  from  the  trophoderm  by  a 
considerable  amount  of  mesoderm. 

In  a  slightly  older  embryo  (14-15  days)  described  by  Peters,  the 
embryonic  disk  is  a  more  definite  structure,  the  ectoderm  being  a  flat 
layer  of  stratified  or  pseudostratified  cells  and  the  margin  reflected  upward 
as  the  lining  of  the  roof  of  the  amniotic  cavity,  and  the  entoderm,  sepa- 
rated from  the  ectoderm  by  a  definite  layer  of  mesoderm,  reflected 
downward  as  the  lining  of  the  yolk  cavity  (Fig.  73).  The  most  con- 
spicuous difterence  between  this  and  the  Bryce-Teacher  embryo  is  the 
large  cavity  within  the  ovum.  This  has  apparently  arisen  through  a 
splitting  of  the  loosely  arranged  mesoderm,  the  peripheral  portion  of 
the  latter  clinging  to  the  trophoderm  and  a  remaining  portion  to  the 
entoderm  of  the  yolk  cavity.  The  trophoderm  and  peripheral  meso- 
derm together  constitute  the  chorion.  The  entoderm  and  tlie  mesoderm 
clinging  to  it,  form  the  yolk  sac.  The  ectodermal  roof  of  the  amniotic 
cavity  and  the  apposed  mesoderm  form  the  amnion.  The  yolk  sac, 
embryonic  disk  and  amnion  are  attached  to  the  chorion  by  the  meso- 
derm of  the  amnion.  The  large  cavity  within  the  chorionic  vesicle  is  the 
extra-embryonic  body  ca^'ity  or  exocelom. 

While  neither  of  the  human  ova  just  considered  gives  any  clue  to  the 
origin  of  the  germ  layers,  they  are  of  extreme  interest  and  importance 
in  that  they  show  the  earliest  known  conditions  in  the  development 
of  the  human  being,  and  furthermore,  show  a  very  early  stage  of  differ- 
entiation in  the  structures  which  give  rise  on  the  one  hand  to  embryo 
proper  and  on  the  other  hand  to  embryonic  appendages  essential  to 
intra-uterine  life. 

Further  Development  of  the  Germ  Layers. — Body  Form. — To  return 
to  the  embryonic  disk  in  a  mammal,  the  dog  for  example,  it  will 
be  remembered  that  the  disk,  composed  of  ectoderm,  mesoderm  and 
entoderm,  was  generally  circular  in  shape  and  that  the  three  germ 
layers  were  fused  in  the  primitive  streak  which  extends  from  a  point 
near  the  centre  to  the  margin  of  the  disk  (Figs.  56  and  57).  And  it 
should  be  noted  here  that  the  primitive  streak  not  only  indicates  the 
direction  of  the  long  axis  of  the  future  embryo  but  also  marks  the  caudal 
end  of  the  body;  and  that  consequently  the  body  will  develop  between 
the  primitive  node  and  the  opposite  margin  of  the  disk. 


CLEAVAGE  AND  FORMATION  OF  THE  GERM  LAYERS         75 

Sections  of  the  embryonic  disk,  taken  in  front  of  the  primitive  streak 
node  and  at  right  angles  to  the  projected  hne  of  the  primitive  streak, 
show  the  mesoderm  and  entoderm  fused  and  the  ectoderm  as  a  distinct 
and  separate  layer  (Figs.  58  and  59).  This  condition  probabl}^  arises 
from  that  seen  in  the  primitive  streak  by  means  of  a  separation  of  the 
ectoderm  from  the  other  two  layers  and  a  concomitant  recession  of  the 
front  end  of  the  streak.  While  this  process  is  not  extensive  it  nevertheless 
yields  a  short  band  of  cells  composed  of  fused  mesoderm  and  entoderm, 
extending  forward  from  the  primitive  streak.     These  cells  proliferate 


'v: 


.  *  "St**  e 


^J.^uV'i^''^  ""     ""s'  -     i   ,      ®-    ^    Mesoderm 

Entoderm 


^^^^  ^  S  -«.    — r       '  -^^^^to^  ^^-—  --^ -«^^*!:^ 


-«)**> 


Kctodenn 


«^'^y^'~"  f^^    ^-    ^         ^*0^^^    "e"^    *    '^       ^     Mesoderm 


^^3>  0        0^  Entoderm 

,®    ^ 
.^    ® 

Figs.  58  and  59. — From   transverse  sections  of  the  embryonic  disk  of   a  dog.    Sections 
taken  from  upper  third  of  disk  shown  in  Fig.  56.      (Bonnet.) 

rapidly  and  soon  give  rise  to  an  opaque  band  prominent  enough  to  be 
seen  from  the  surface  of  the  disk.  This  band  is  known  as  the  primitive 
axis  (head  process),  and  corresponds  to  the  region  in  which  the  body 
proper  of  the  embryo  develops  (Fig.  60). 

While  the  primitive  axis,  as  such,  is  still  increasing  in  length  a  separa- 
tion is  effected  between  entoderm  and  mesoderm  near  its  anterior  end 
and  the  mesoderm  itself  is  divided  in  the  median  line,  thereby  giving 
rise  to  the  condition  shown  in  Fig.  61 .  This  process  continues  from  before 
backward  along  the  primitive  axis  to  the  point  where  the  axis  becomes 


76 


EMBRYOLOGY  AND  PHYSIOLOGY 


continuous  with  the  primitive  streak.  Here  the  axis  can  increase  by  the 
same  process  that  gave  it  origin,  namely,  the  separation  of  the  ectoderm 
from  the  fused  mesoderm  and  entoderm.  The  mass  of  cells  in  the  region 
of  the  primitive  streak,  having  iu'  the  meantime  increased  in  volume, 
but  still  representing  all  three  germ  layers,  is  known  as  the  trunk  bud 
(or  tail  bud).      The  processes  of  differentiation  and  development,  as 


Hensen's 
node 


Primitive 
streak 


Primitive  axis 


Fig.  60. — Surface  view  of  the  embryonic  disk  of  a  dog.     (Bonnet.) 

exemplified  by  the  changes  in  the  primitive  axis  noted  above  in  general 
begin  in  the  anterior  or  cephalic  region  of  the  embryonic  body  and  pro- 
gress toward  the  posterior  or  caudal  region.  Out  of  the  trunk  bud, 
therefore,  are  difi'erentiated  the  germ  layers  in  discrete  form,  the 
bud  itself  gradually  receding  as  other  structures  develop  in  front  of  it 
and  the  embryonic  body  increases  in  length. 


Neural  folds 


Entoderm 

Fig.  61. — From  a  transverse  section  of  the  embryonic  disk  of  a  dog.    Section  taken  at  level 

of  Ss  in  Fig.  60.     (Bonnet.) 

Changes  in  the  Mesoderm.  Origin  of  the  Celom.^ — After  the  mesoderm 
has  divided  along  the  axial  line,  as  shown  in  Fig.  61,  numerous  slight 
fissures  appear  in  it  and  gradually  coalesce  to  form  two  slit-like  cavities, 
one  on  each  side,  situated  a  short  distance  from,  and  extending  parallel 
to,  the  median  line.  These  cavities  enlarge  as  the  mesoderm  continues 
to  split  in  the  lateral  direction  and  eventually  become  continuous  with 


CLEAVAGE  AND  FORMATION  OF  THE  GERM  LAYERS 


77 


the  wide  space  around  the  yolk  cavity  which  in  man  and  the  higher 
animals  develops  at  an  early  stage  and  which  has  already  been  noted  as 
the  extra-embryonic  body  cavity  (see  page  74).  With  the  exception 
of  a  portion  along  the  axial  line,  which  will  be  considered  subsequently, 
the  mesoderm  is  thus  split  into  two  layers.  The  outer  layer,  which 
remains  apposed  to  the  ectoderm,  is  the  somatic  or  parietal  mesoderm. 
The  inner  layer,  closely  applied  to  the  entoderm,  is  the  visceral  or 
splanchnic  mesoderm  (Fig.  62). 

The  new  cavity  now  separating  these  two  layers  is  the  celom.  The 
portion  that  becomes  enclosed  within  the  body  is  the  forerunner  of  the 
three  great  serous  cavities  of  the  adult,  namely,  the  pleural,  pericardial, 
and  peritoneal  cavities.  The  angle  formed  by  the  junction  of  the  somatic 
and  splanchnic  layers  of  mesoderm  near  the  axial  line  of  the  embryo  is 
the  celomic  angle.  The  extra-embryonic  portion  of  the  celom  consti- 
tutes the  large  space  separating  the  amnion  and  yolk  sac  from  the  chorion. 


Neural 
groove 


Meso-      Inter- 
dermic    mediate 
somite  cell  mass 


Parietal  and 
visceral  mesoderm    Ectoderm 


Celom    Entoderm 
Fig.  62. — From  a  transverse  section  of  a  dog  embryo  with  10  primitive  segments.     (Bonnet.) 


As  the  celom  develops  the  cells  bounding  it  become  flat  or  scale-like 
and  form  a  pavement  or  simple  squamous  epithelium.  This  is  known  as 
mesothelium  and  constitutes  the  lining  of  the  large  serous  cavities  men- 
tioned in  the  preceding  paragraph. 

The  somatic  mesoderm  and  the  apposed  ectoderm  together  constitute 
the  splanchnopleure.  These  two  double  layers  are  to  a  great  degree 
elementary  parts  out  of  which  adult  structures  are  produced.  Although 
the  cells  in  each  are  derived  from  two  germ  layers,  they  are  intimately 
associated  in  the  development  of  certain  organs.  In  each,  moreover, 
it  is  convenient  to  distinguish  between  an  embryonic  portion,  which 
enters  into  the  formation  of  the  embryo  proper,  and  an  extra-embryonic 
portion  which  gives  rise  to  embryonic  appendages  that  are  lost  at  birth. 
In  general  the  embryonic  portion  of  the  somatopleure  is  concerned  in  the 
formation  of  the  body  wall,  while  the  corresponding  portion  of  the 
splanchnopleure  gives  rise  to  visceral  structures. 


78 


EMBRYOLOGY  AND  PHYSIOLOGY 


Mesodermic  Somites. — Metamerism. — There  remains  to  be  considered 
the  band  of  mesoderm  along  each  side  of  the  median  line  in  which  in  the 
higher  forms  there  is  but  slight  indication  of  a  separation  into  a  parietal 
and  a  \isceral  la>er.  Soon  after  the  mesoderm  breaks  away  from  the 
entoderm  along  the  ])riniitive  axis,  a  loosening  of  the  cells  occurs  in  a 
narrow,  transverse  line  in  the  mesoderm  a  short  -distance  in  front  of  the 
primitive  streak.  Almost  immediately  a  similar  trans^'erse  loosening 
of  the  cells  takes  place  near  b>-.  The  mesoderm  is  thereby  cleft  twice, 
the  cells  between  the  clefts  constituting  a  mesodermic  somite;  and  since 
the  i)hen()mena  are  identical  on  both  sides  of  the  median  line,  two  somites 
are  formed  which  are  bilaterallv  s^'mmetrical. 


Telencephalon 
Diencephalon 
Mesencephalon 

Metencephalon 

Myelencephalon 


Fig.  63. — Dorsal  view  of  a  doK  niilnyo  with  10  primitive  segments.     (Bonnet.) 

The  first  pair  of  somites  develops  in  what  will  be  the  occipital  region 
of  the  embryo.  All  further  somites  are  formed  successively  in  the  same 
manner  as  the  first  pair,  the  series  growing  by  additions  from  the  meso- 
derm l)etween  those  already  formed  and  the  primitive  streak,  thus  again 
exemplifying  the  progress  of  devek)pment  from  the  head  of  the  embryo 
toward  the  caudal  region   (Fig.  (),')). 


CLEAVAGE   AXD   FORMATION  OF    THE   GERM  LAYERS  79 

Between  each  somite  and  the  celom  there  is  left  a  small  group  of  cells, 
fused  both  with  the  somite  and  the  parietal  and  visceral  mesoderm. 
This  is  the  intermediate  cell-mass,  or,  since  it  subsequently  gives  rise  to 
a  part  of  the  urinary  system,  is  spoken  of  as  the  nephrotome.  These 
structures,  corresponding  to  the  somites,  are  bilaterally  s\Tnmetrical  and 
segmentally  arranged. 

The  only  indication  of  a  splitting  of  the  mesoderm  in  the  higher  verte- 
brates in  the  region  under  consideration  is  a  Iqosening  of  the  cells  in  the 
central  portion  of  the  somite.  In  the  lower  vertebrates  and  many  inver- 
tebrates the  celom  extends  tlirough  the  nephrotome  into  the  somite, 
thereby  leaving  the  somatic  and  splanchnic  mesoderm  connected  only 
by  the  mesial  wall  of  the  somite. 

In  the  formation  of  the  mesodermic  somites  is  expressed  the  beginning 
of  the  segmentation  of  the  body,  or  metamerism,  characteristic  of  all 
vertebrates  and  many  of  the  invertebrates.  The  somites  themselves 
are  the  primary  morphological  segments,  and  each  pair  is  called  a  primi- 
tive segment.  They  produce  during  development  many  structures  which 
are  arranged  in  series  in  the  adult.  For  example,  the  history  of  the 
vertebrae,  the  ribs  and  many  of  the  muscles,  especially  the  intercostal 
muscles,  depends  upon  their  segmental  origin.  jMoreover  the  nervous 
system,  as  well  exemplified  in  the  spinal  nerves,  and  to  a  considerable 
extent  the  bloodvessels,  exhibit  a  metameric  arrangement  correlated 
with  the  mesodermic  segmentation. 

Derivatives  of  the  Germ  Layers. — The  germ  lasers,  as  already  seen,  differ 
from  one  another  not  only  in  position  but  also  in  structure.  Their 
formation  constitutes  a  fundamental  differentiation  of  the  cells  of  the 
developing  organism.  By  constantly  increasing  differentiation  all  the 
tissues  and  organs  of  the  body  are  produced,  each  layer  giving  rise  to 
its  own  special  group.  In  general  terms  it  can  be  stated  that  ectoderm 
gives  rise  to  the  covering  of  the  body,  namely,  the  epidermis,  the  most 
important  function  of  which  is  protection,  and  to  that  mechanism  which 
enables  the  animal  to  react  to  stimuli — the  nervous  system;  that  the 
entoderm  produces  the  epithelium  of  the  alimentary  tract  and  appended 
organs;  and  that  mesoderm  is  mainly  concerned  in  the  formation  of  the 
various  supporting  and  coimective  tissues,  although  it  gives  rise  also  to 
the  epithelium  of  the  genito-urinary  and  vascular  systems.  The  quality 
by  virtue  of  which  each  layer  gives  rise  only  to  certain  tissues,  or  more 
particularly  to  parts  of  certain  organs,  is  known  as  the  specificity  of  the 
germ  layers.    The  tissue  derivatives  of  the  germ  layers  are  as  follows: 

Ectoderm. ^1.  Epithelium  of  skin  and  its  appendages — hair,  nails, 
sweat  glands  (and  their  smooth  muscle),  sebaceous  glands  and  mammary 
glands. 

2.  Nervous  system  (central  and  peripheral),  neuroglia,  retina. 

3.  Epithelium  of  mouth  and  anus,  of  glands  opening  into  mouth, 
enamel  of  teeth. 

4.  Epithelium  of  nasal  passages  and  connected  glands  and  cavities. 

5.  Epithelium  of  external  auditory  canal  and  membranous  labyrinth. 


80  EMBRYOLOGY  AND  PHYSIOLOGY 

6.  Epithelium  of  anterior  surface  of  cornea  and  of  conjunctiva,  crys- 
talline lens. 

7.  Epithelium  of  penile  portion  of  urethra. 

8.  Epithelium  of  pituitary  body. 

9.  Chromaffin  tissue. 

Entoderm. — 1.  Epithelium  lining  alimentary  tract  (except  mouth  and 
anus)  and  of  glands  connected  with  the  tract. 

2.  Epithelium  of  trachea  and  lungs. 

3.  Epithelium  of  thyroid   (including  lateral  thyroids),  parathyroids, 
reticulum  and  Hassall's  corpuscles  in  thymus. 

4.  Epithelium  of  middle  ear  and  Eustachian  tube. 

5.  Epithelium  of  bladder  (except  trigonum),  female  urethra,  prostatic 
portion  of  male  urethra. 

Mesoderm. — 1.  All  connective  tissues  except  neuroglia. 

2.  Striated,  cardiac  and  smooth  muscle. 

3.  Epithelium  of  genito-urinary  system  (except  urethra  and  greater 
part  of  bladder). 

4.  Lymph  organs   (excluding  reticulum  and  Hassall's  corpuscles  in 
thymus),  blood  cells,  bone-marrow. 

5.  Epithelium  (endothelium)  of  bloodvessels  and  Ijmiph  vessels. 

6.  Epithelium  (mesothelium)  lining  the  serous  cavities. 

7.  Epithelium  of  cortex  of  adrenal  gland. 


MENSTRUATION. 

At  intervals  during  the  child-bearing  age  of  a  healthy  woman  there 
occurs  a  series  of  phenomena  which,  from  its  monthly  periodicity,  is 
called  menstruation.  Much  of  the  process  of  menstruation  and  many 
of  its  relations  are  not  thoroughly  understood.  It  is  well  known,  how- 
ever, that,  beginning  with  puberty  and  ending  with  the  menopause, 
except  during  pregnancy  and  lactation,  there  is  a  time  each  month 
when  the  normal  woman  presents  local  and  general  symptoms  which 
are  characteristic  of  her  sex.  Of  these  the  most  pronounced  is  a  dis- 
charge of  blood  from  the  uterus. 

While  menstruation,  as  a  rule,  ceases  during  pregnancy,  it  occasionally 
occurs  during  the  early  months  of  pregnancy  before  the  decidua  capsularis 
(reflexa)  reaches  the  decidua  parietalis  (vera)  and  closes  the  uterine 
cavity.  The  closure  takes  place  about  the  middle  of  pregnancy,  and 
after  this  time  true  menstruation  is  regarded  as  impossible.  Absence 
of  menstruation  is  the  rule  also  during  lactation.  Many  exceptions  are 
met  with,  however,  and  not  infrequently  a  woman  will  menstruate  regu- 
larly throughout  the  entire  lactation  period. 

The  menstrual  cycle  can  be  divided  into  four  periods  during  which 
the  uterine  mucosa  exhibits  more  or  less  definite  histological  changes. 
The  longest  period  is  the  interval  or  intermenstrual  period,  lasting  about 
fourteen  days.  Following  this,  without  sharp  limitation,  is  the  pre- 
menstrual period  of  six  or  seven  days.    This  leads  to  the  period  of  men- 


MENSTRUATION  81 

struation,   from   three   to  five   days   in  duration.     The  postmenstrual 
period,  of  from  four  to  six  days,  completes  the  cycle. 

The  mucous  membrane  of  the  uterus  during  the  intermenstrual  period 
(Fig.  64)  is  usually  described  as  normal  or  resting,  although  it  undergoes 
a  slight  increase  in  thickness.  It  is  on  the  average  2  millimeters  thick. 
The  surface  epithelium  is  simple  columnar  or  cuboidal,  with  varying 
amounts  of  ciliation.  The  glands  are  of  the  simple  or  sparingly  branched 
tubular  type  and  are  directed  obliquely  to  the  surface.  The  glands 
usually  reach  all  the  way  through  the  mucosa  and  occasionally  extend 
into  the  deepest  layer  of  the  muscle  coat.  The  gland  epithelium  is 
nonciliated,  simple  cuboidal  or  columnar,  the  cells  being  small  during 


|Si         (J  '  ■£>■■  "X,  rf 


W'l 


0>  '       O' 


.  D 


i-*v 


Fig.  64. — From  a  section  of  the  uterine  mucosa  during  the  intermenstrual  period. 
(Hitschmann  and  Adler.) 

the  first  half  of  the  period  but  during  the  second  half  increasing  in  size 
and  acquiring  an  acidophile  character.  The  stroma  resembles  a  richly 
cellular  embryonic  connective  tissue,  in  which  the  fibers  are  extremely 
delicate  and  the  cells  irregularly  stellate  or  fusiform  in  shape  with  rela- 
tively large  nuclei.  Small  lymph  nodules  and  scattered  lymphocytes 
are  present.  Toward  the  end  of  the  intermenstrual  period  the  gland 
cells  produce  granules  which  are  discharged  into  the  lumina  of  the  glands. 
The  stroma  becomes  slightly  edematous. 

During  the   premenstrual  period    (Fig.   65)   the  mucous  membrane 

rapidly  increases  in  thickness  up  to  4  to  6  millimeters.     The  increase  is 

due  to  greater  edema,  enlargement  of  the  component  cells,  and,  toward 

the  end  of  the  period,  engorgement  of  the  bloodvessels.     The  glands 

6 


82 


EMBRYOLOGY  AND  PHYSIOLOGY 


Fig.  65. — From  a  section  of  the  uterine  mucosa,  showing  the  premenstrual  condition. 

(Hitschman  and  Adler.) 


Fig. 


GO. — From  a  section  of  the  uterine  mucosa  (endometrium).    Premenstrual  liyperplasia, 
one  day  before  menstrual  date.     (Photograph.) 


MENSTRUATION  83 

become  much  larger,  principally  in  their  deeper  portions,  through  enlarge- 
ment of  the  cells  and  free  discharge  of  secretion  into  the  lumina  (Fig. 
66).  The  secretion  changes  to  mucus.  The  connective-tissue  (stroma) 
cells,  especially  near  the  surface  of  the  mucosa,  increase  in  size,  and 
assume  roundish  or  polygonal  shapes,  both  cytoplasm  and  nuclei  losing 
much  of  their  affinity  for  dyes.  These  larger,  clearer  cells  resemble 
closely  the  decidual  cells  that  differentiate  from  the  stroma  cells  during 
pregnancy  (see  p.  103),  and  in  fact  are  often  called  decidual  cells  of 
menstruation.  On  account  of  the  localization  of  the  changes  in  the 
glands  and  stroma,  two  layers  can  be  distinguished  in  the  mucosa — a 
superficial  compact  layer  and  a  deep  spongy  layer  (Fig.  6.5).  With 
the  engorgement  of  the  bloodvessels,  numerous  small  extravasations 
occur  which  reach  the  surface  of  the  mucosa,  the  epithelium  is  torn  and 
the  blood  escapes  into  the  uterine  cavity.  This  is  the  beginning  of  actual 
menstruation. 


m^ 


Fig.  67. — From  a  section  of  the  uterine  mucosa.     Condition  on  the  third  daj-  of  menstrua- 
tion, showing  separation  of  the  superficial  layer.     (Hitschmann  and  Adler.) 

During  the  menstrual  period  (Fig.  67)  there  occur  an  effusion  of  blood 
and  edema  fluid  and  an  expulsion  of  the  glandular  secretion  into  the 
uterine  cavity,  and  a  concomitant,  rapid  shrinkage  of  the  mucous  mem- 
brane. The  surface  epithelium  may  be  in  part  retained  or,  as  the 
other  extreme,  may  be  wholly  expelled  along  with  the  greater  part 
of  the  compact  layer  of  stroma.  In  the  latter  case  there  are  usually 
painful  contractions  of  the  musculature  of  the  uterus.  The  glands, 
their  contents  discharged,  diminish  in  size  and  the  cells  become  smaller; 
there  may  be  considerable  desquamation.  Many  of  the  stroma  cells 
break  down  and  are  expelled  or  carried  off  by  leukocytes;  the  rest 
decrease  in  size  and  become  fusiform.  The  surface  epithelium  is  always 
regenerated  by  the  time  menstruation  has  ceased. 

In  the  early  part  of  the  postmenstrual  period  (Fig.  68)  the  mucous 
membrane  is  thin,  with  straight,  narrow  glands  and  closely  packed,  fusi- 
form stroma  cells  (Fig.  69).  The  glands  then  slowly  increase  in  size,  the 
stroma  cells  become  more  succulent  and  the  mucosa  as  a  whole  returns 
to  the  relatively  quiescent  condition  of  the  intermenstrual  period. 


84 


EMBRYOLOGY  AND  PHYSIOLOGY 


Ij4»"'  St    -  *^^ 


Fig    GS. — From  a  section  of  the  uterine  mucosa.     Postmenstrual  condition,  one  day  after 
menstruation.     (Hitschmann  and  Adler.) 


Fig.  G9. — From  a  section  of  the  uterine  mucosa  (endometrium).     Postmenstrual  gUinds. 
Reparative  stage.     Mitosis  in  epithelial  cells  of  gland.     (Photograph.) 


MENSTRUATION  85 

The  bleeding  during  menstruation  occurs  in  the  body  and  fundus  of 
the  uterus.  The  cervix,  although  congested,  is  regarded  as  taking  little 
or  no  part  in  actual  menstruation.  The  blood,  as  discharged  from  the 
vagina,  is  mixed  with  cells  from  the  uterine  mucosa  and  with  the  secre- 
tion of  the  uterine  glands  (mucus),  coagulation  being  prevented  probably 
by  the  mucus.  It  has  a  peculiar  penetrating  odor.  The  amount  of  blood 
discharged  is  difScult  to  estimate,  but  varies  greatly  in  different  indivi- 
duals. Five  or  six  ounces  are  regarded  as  an  average  loss.  The  duration 
of  menstruation  also  varies  in  different  women  of  good  health,  the  flow 
not  lasting  longer  than  two  days  in  some  and  as  long  as  a  week  in  others. 
Four  or  five  days  may  be  considered  an  average. 

The  type  or  periodicity  of  menstruation  varies  to  a  considerable  degree. 
In  about  86  per  cent,  the  periods  are  regular;  that  is,  there  is  uniformly 
the  same  number  of  days  from  the  beginning  of  one  period  to  the  begin- 
ning of  the  next.  The  most  common  is  the  twenty-eight-day  type;  the 
next  most  most  common  is  the  thirty-day  type;  a  few  show  the  twenty- 
one-day  type,  and  in  some  there  seem  to  be  no  typical  occurrence.  As 
healthy  woman  has  been  known  to  menstruate  regularly  every  forty- 
two  days. 

The  changes  in  other  parts  of  the  body,  accompanying  the  menstrual 
(structural)  changes  in  the  uterus,  are  marked  in  some  women  but 
scarcely  noticeable  in  others.  The  breasts  are  often  enlarged  and  tender. 
The  glands  about  the  vulva  may  show  stimulation.  The  thyroid,  the 
parotids  and  the  tonsils  are  not  infrequently  enlarged.  Increased  pig- 
mentation about  the  eyes  and  breasts  is  common.  The  individual  is 
usually  more  excitable  and  self-control  is  more  difficult  to  maintain. 
There  is  usually  a  feeling  of  weight  in  the  pelvis  owing  to  congestion 
of  the  pelvic  organs.  Many  complain  at  the  beginning  of  the  period  of 
a  feeling  of  fulness  in  the  head  and  back.  Just  before  the  flow  there 
is  frequently  a  slight  rise  in  temperature  (one-half  of  one  degree),  pulse- 
rate,  and  arterial  tension.  Following  the  establishment  of  the  flow  there 
is  a  corresponding  decline. 

The  Age  of  Puberty. — The  first  appearance  of  menstruation  is  usually 
regarded  as  marking  the  transition  from  girlhood  to  womanhood,  or  the 
age  of  puberty,  when  the  generative  organs  become  functionally  mature. 
Exceptionally  menstruation  may  begin  in  infancy  or  later  than  puberty. 
Rarely  it  begins  in  a  woman  only  after  she  has  given  birth  to  a  child. 

The  age  at  which  sexual  maturity  occurs  varies  greatly  in  different 
climates,  different  races,  and  different  families.  It  is  also  influenced  by 
mode  of  life  and  environment.  Women  in  temperate  climates  as  a  rule 
begin  to  menstruate  earlier  than  those  in  cold  climates  and  later  than 
those  in  warm  climates.  In  temperate  climates  and  among  Anglo- 
Saxon  women,  the  age  of  thirteen  to  fourteen  years  may  be  considered 
the  usual  age  of  puberty.  One  hundred  consecutive  cases  taken  from 
my  private  case-book  show  that  menstruation  began  at  ten  years  in  1; 
at  eleven  years  in  5;  at  twelve  years  in  8;  at  thirteen  years  in  twenty- 
seven;  at  fourteen  years  in  28;  at  fifteen  years  in  14;  at  sixteen  years 
in  8;  at  seventeen  years  in  9.    Thus  at  thirteen  to  fourteen  years  of  age 


86  EMBRYOLOGY  AND  PHYSIOLOGY 

menstruation  began  in  55  per  cent,  of  cases  met  with  in  private  practice 
among  American  women  in  New  York  City.  Jewesses,  as  a  rule,  men- 
struate earlier  than  Anglo-Saxon  women.  In  some  families  menstruation 
is  uniformly  late  in  beginning;  in  other  families  it  appears  uniformly 
early.  Girls  brought  up  in  the  city,  who  lead  a  life  of  high,  nervous 
tension,  surrounded  by  many  means  of  sexual  excitement,  menstruate 
earlier  than  those  reared  in  the  country,  who  eat  plain  food,  retire  early, 
and  spend  much  time  out  of  doors. 

In  the  establishment  of  menstruation  it  is  not  an  uncommon  experi- 
ence for  a  girl  to  menstruate  once  or  twice  and  then  not  again  for  several 
months,  or  a  year,  when  menstruation  returns  and  continues  regularly. 
In  the  interval  of  amenorrhea  there  may  or  may  not  be  present  at  monthly 
intervals  the  feeling  of  weight  in  the  pelvis  and  fulness  and  throbbing 
in  the  head  and  back,  without  the  bloody  discharge. 

With  the  appearance  of  menstruation  other  evidences  of  sexual  maturity 
are  usually  associated.  Hair  appears  upon  the  mons  veneris  and  labia 
majora  and  in  the  axillae,  the  breasts  enlarge,  the  hips  become  broader, 
and  the  general  contour  of  the  body  becomes  more  rounded. 

The  Menopause. — The  cessation  of  menstruation,  or  the  menopause, 
occurs  at  different  ages  in  different  people.  In  the  climate  of  New  York 
the  average  age  is  about  fifty  years.  Many  women  who  begin  to  men- 
struate late  cease  menstruation  early.  On  the  other  hand,  many  who 
begin  to  menstruate  early  do  not  cease  menstruation  till  they  reach  the 
age  of  fifty-two  to  fifty-five.  This  varies  greatly  in  different  families. 
The  menopause  may  be  established  abruptly  but  often  there  is  a  period 
of  a  year  or  two  in  which  menstruation  becomes  more  and  more  infre- 
quent and  irregular. 

Many  marked  exceptions  to  the  usual  ages  for  puberty  and  the  meno- 
pause are  recorded  as,  for  instance,  where  children  began  to  menstruate 
between  one  and  two  years  of  age  and  where  women  did  not  reach  the 
menopause  till  after  sixty.  These  must  be  looked  upon  merely  as  irreg- 
ular types  and  the  years  from  thirteen  to  fifty  be  regarded  as  the  usual 
ages  of  sexual  maturity  and  possible  child-bearing.  With  the  appearance 
of  the  menopause  women  usually  suffer  more  or  less  with  a  lack  of  balance 
of  the  vasomotor  and  general  nervous  system.  Frequent  flushings  of 
the  face,  perspirations  and  nervous  irritability  are  well  known  and 
generally  recognized.  At  this  time  the  woman  generally  adds  to  her 
weight.  Her  abdominal  wall  especially  increases  its  fat  and  she  often 
suffers  with  flatulence  and  other  expressions  of  intestinal  indigestion. 

Relation  of  Menstruation  to  Ovulation. — There  are  still  several  con- 
flicting opinions  as  to  the  relationship  between  these  two  series  of  phe- 
nomena. That  menstruation  is  dependent  upon  periodic  activities  of  the 
ovaries  seems  clearly  demonstrated.  If  both  ovaries  are  removed  men- 
struation ceases  and  the  uterus  atrophies.  If  both  ovaries  fail  to  develop 
the  condition  of  amenorrhea  exists.  In  cases  of  removal  or  congenital 
absence  of  both  ovaries  a  piece  of  ovary  transplanted  into  the  broad 
ligament  or  uterus,  or  even  under  the  skin,  occasionally  brings  on  men- 
struation, although  this  is  apt  to  be  irregular. 


MENSTRUATION 


87 


INIany  facts  have  been  accumulated  by  gynecologists  to  show  that 
ovulation  may  occur  independently  of  menstruation.  For  example, 
impregnation  may  occur  during  lactation  when  the  menstrual  function 
is  in  abeyance,  and  it  may  occur  in  young  girls  before  the  onset  of  men- 
struation or  in  women  after  the  menopause.  Some  years  ago  the  author 
was  obliged  to  remove  from  a  woman  who  had  not  menstruated  for  seven 
years  the  ovaries  shown  in  the  accompanying  illustration  (Fig.  70). 
One  ovary  contained  a  fresh  corpus  luteum  showing  that  the  woman 
was  ovulating  in  spite  of  her  amenorrhea.  It  is  generally  conceded,  how- 
ever, that  as  a  rule  ovulation  and  menstruation  occur  in  a  definite  sequence 
and  that  the  significance  of  menstruation  is  to  be  found  in  its  physio- 


FiG.  70. 


-Ovaries  of  a  woman  who  had  not  menstruated  for  seven  years,  sho'U'ing  a  fresh 
corpus  luteum.     (Photograph.) 


logical  connection  with  the  fate  of  the  ovum,  i.  e.,  whether  it  is  to  be 
fertilized  or  not. 

The  older  view  (Pfliiger)  was  that  the  uterus  was  influenced  by  pro- 
cesses in  the  ovary  through  nervous  reflex.  ]\Iore  recently  it  has  been 
shown  experimentally  in  the  dog  that  when  the  nerves  supplying  the 
uterus  are  cut  the  animal  can  nevertheless  become  pregnant  and  bear 
offspring.  The  transplantation  experiments  mentioned  above  also  show 
that  the  connection  between  the  ovary  and  uterus  is  not  essentially 
nervous  in  character.  The  present  view  is  that  the  influence  upon  the 
uterus  is  brought  about  through  the  blood  and  is  based  upon  the  very 
reasonable  assumption  that  the  ovary  elaborates  an  internal  secretion. 


88  EMBRYOLOGY  AND  PHYSIOLOGY 

The  latter  view  is  strongly  supported  by  Fraenkel,  who  believes  that 
the  internal  secretion  is  furnished  by  the  cells  of  the  corpus  luteuni. 
This  observer  holds  that  ovulation  nomiallx"  occurs  two  weeks  ])rior  to 
menstruation  and  that  the  activity  of  the  lutein  cells  is  responsible  for 
the  secretion  (hormone)  which  stimulates  the  uterine  mucosa  to  the 
growth  that  takes  place  during  the  premenstrual  period. 

FETAL   MEMBRANES. 

Stated  in  very  general  terms,  the  fetal  membranes  are  certain 
structures  that  develop  from,  or  as  parts  of,  the  embr>'o,  functionate 
for  a  period,  during  which  the  embryo  is  dependent  upon  its  immediate 
environment,  as  organs  of  nutrition  and  excretion,  and  then,  when  the 
embryo  is  able  to  maintain  an  independent  existence,  are  cast  off  or 
atrophy  and  disappear.  More  specifically,  the  human  fetal  membranes 
are  structures  of  the  above  nature,  which  establish  an  extraordinarily 
intimate  structural  and  functional  relationship  between  the  embryo  and 
the  maternal  tissues,  by  virtue  of  which  the  embryo  is  nourished  and 
discharges  its  waste  products  during  gestation. 

Under  this  head  are  to  be  considered  (1)  the  yolk  sac,  (2)  the  amnion, 
(3)  the  chorion,  (4)  the  allantois,  and  (5)  the  umbilical  cord.  In  addi- 
tion it  is  necessary  to  discuss  also  the  changes  in  the  mucous  membrane 
of  the  uterus  since  this  is  particularly  affected  by  the  growth  of  the 
chorion. 

In  the  different  mammals  there  is  much  variation,  not  only  in  the 
origin  of  the  fetal  membranes,  but  also  in  their  ultimate  structure  and 
the  relationship  established  with  the  uterine  mucosa.  In  some  forms 
the  amnion  appears  as  folds  of  the  somatopleure  (ectoderm  plus  parietal 
mesoderm)  which  grow  dorsally  and  eventually  meet  and  fuse  dorsal  to 
the  embryonic  body.  The  inner  limb  of  the  fold,  formed  from  without 
inward  of  parietal  mesoderm  and  ectoderm,  constitutes  the  amnion, 
the  cavity  between  it  and  the  embryo  being  the  amniotic  cavity  (Fig. 
71).  The  outer  limb  of  the  fold,  formed  from  within  outward  of  parietal 
mesoderm  and  ectoderm,  constitutes  a  portion  of  the  chorion  which  is, 
of  course,  continuous  with  the  more  peripheral  part  of  the  somatopleure, 
the  cavity  between  the  amnion  and  chorion  being  a  continuation  of  the 
extra-embryonic  body  cavity  (Fig.  71).  This  cavity  gradually  extends 
around  the  original  yolk  cavity  through  splitting  of  the  mesoderm,  so 
that  eventually  the  portion  of  the  somatopleure  forming  the  chorion  is 
separated  from  the  splanchnopleure  which  now  forms  the  yolk  sac. 

The  embryonic  body,  as  it  develops,  becomes  constricted  from  the 
yolk  sac,  a  small  portion  of  the  latter  being  included  in  the  body  as  the 
primitive  gut  which  remains  attached  to  the  yolk  sac  by  means  of  the 
yolk  stalk  (Fig.  71).  With  this  constriction  the  border  of  the  amnion  is 
carried  ventrally  and  eventually  the  amnion,  gradually  increasing  in 
size,  surrounds  the  embryo  like  a  sac,  being  attached  in  annular  form 
to  the  ventral  side  of  the  embryo  (Fig.  71).  The  allantois  develops 
as  a  diverticulum  from  the  caudal  end  of  the  gut  and  grows  out  into  the 


FETAL  MEMBRANES 


89 


extra-embryonic  body  cavity  as  a  sac-like  structure  which  finally  fuses 
with  the  chorion  (Fig.  71).  As  the  embryo  becomes  constricted  from 
the  yolk  sac  the  amnion  enlarges,  as  noted  above,  and  pushes  together 
the  yolk  stalk  and  the  narrow  proximal  portion  of  the  allantois,  or  allan- 
toic duct.     There  is  thus  formed  a  cylindrical  structure,  the  umbilical 


Embryonic  disk 


Exocelom 


Amniotic  folds 


Chorionic  villi 


Chorionic  villi 
Chorion 


Allantois 


Exocelom 


Fig.  71. — Diagrams  of  the  development  of  the  fetal  membranes  in  a  mammal.    A,  B,  C, 
represent  cross-sections;  D,  represents  a  longitudinal  section.      (Bonnet.) 


cord,  which  is- covered  with  ectoderm  and  includes  not  only  the  yolk 
stalk  and  allantoic  stalk,  with  their  quota  of  mesoderm  (Fig.  71),  but 
also  the  bloodvessels  whose  branches  ramify  in  the  walls  of  the  yolk 
sac  and  allantois,  the  vitelline  (omphalomesenteric)  and  umbilical 
(allantoic)  vessels  respectively. 


90  EMBRYOLOGY  AND  PHYSIOLOGY 

The  yolk  sac  in  mammals  containing  little  nutriment,  the  vitelline 
vessels  are  of  minor  importance  in  nourishing  the  embryo.  On  the 
other  hand,  the  allantois  fusing  with  the  chorion,  the  latter  becomes 
vascularized  by  branches  of  the  umbilical  vessels;  and  since  the  chorion 
comes  in  contact  with  the  uterine  mucosa  the  umbilical  vessels  thus 
acquire  prime  importance  in  the  nourishment  of  the  embryo  and  elimi- 
nation of  its  waste  products. 

The  chorion,  at  first  possessing  a  smooth  ectodermal  surface,  sub- 
sequently increases  its  surface  area  through  the  development  of  num- 
erous projections,  or  villi  (Fig.  71),  which  involve  both  ectoderm  and 
mesoderm.  The  chorionic  ectoderm,  from  its  functional  character,  is 
given  the  name  trophoderm.  The  chorionic  villi  may  be  rudimentary,  as 
in  the  pig,  or  acquire  an  increasing  degree  of  complexity  up  through  the 
mammalian  series,  eventually  reaching  the  exceedingly  complicated 
condition  characteristic  of  the  human  chorion. 

The  chorion,  lying  within  the  cavity  of  the  uterus,  forms  a  union  with 
the  uterine  mucosa.  The  process  of  union  is  spoken  of  as  placentation. 
The  structural  result  of  the  union  is  known  as  the  placenta.  This  union 
is  obviously  either  an  apposition  or  a  fusion,  and  upon  the  intimacy 
of  the  relationship  is  based  one  of  the  classifications  of  placentae. 

(1)  In  case  the  chorionic  and  uterine  epithelia  are  merely  in  contact 
(as  in  the  pig)  the  placenta  is  a  placenta  epitheliochorialis.  At  par- 
turition the  chorionic  villi  are  withdrawn  from  depressions  in  the  uterine 
mucosa,  like  fingers  from  a  glove,  leaving  the  maternal  mucosa  intact, 
and  no  blood  escapes  from  the  uterine  vessels.  (2)  In  case  the  uterine 
epithelium  is  destroyed  wholly  or  in  part  during  placentation  and  the 
chorionic  ectoderm  (trophoderm)  comes  in  contact  with  the  maternal 
connective  tissue,  the  placenta  is  of  the  syndesmochorialis  type.  At  birth 
some  of  the  smaller  uterine  vessels  are  likely  to  be  torn,  and  a  little  blood 
thus  escape.  (3)  If  the  chorionic  epithelium  comes  in  contact  wath  the 
endothelium  of  the  maternal  vessels  during  the  formation  of  the  placenta 
(as  in  carnivores),  the  placenta  is  of  the  endotheliochorialis  type.  In 
this  case  a  considerable  amount  of  blood  escapes  at  birth,  due  to  rup- 
ture of  the  uterine  vessels.  (4)  If,  during  placentation,  all  the  maternal 
partitions  are  broken  down  and  the  chorionic  ectoderm  comes  in  direct 
contact  with  the  maternal  blood  (as  in  man),  the  placenta  is  a  placenta 
hemochorialis.  At  birth  a  large  quantity  of  blood  escapes  from  the 
uterine  vessels  following  the  separation  of  the  placenta.  In  the  last 
three  instances,  and  notably  in  the  human  subject,  some  of  the  maternal 
tissues  in  addition  to  the  blood  remain  attached  to  the  chorion  and  come 
away  with  it  at  parturition.    These  tissues  constitute  the  decidua. 

Placentse  are  also  classified  on  the  basis  of  form.  In  the  pig  the  villi 
are  more  or  less  uniformly  distributed  over  the  surface  of  the  chorion 
and  the  placenta  is  spoken  of  as  diffuse.  In  other  cases,  while  the  villi 
at  first  developed  uniformly  over  the  surface  of  the  chorion,  they  sub- 
sequently disappear  except  in  definitely  restricted  areas.  If  they  per- 
sist in  groups,  as  in  the  cow  and  sheep,  the  placenta  is  of  the  multiplex 
(cotyledonary)  t\'pe.    When  they  persist  in  an  area  girdling  the  chorion, 


FETAL  MEMBRANES  91 

as  in  the  dog  and  cat,  a  placenta  zonaria  is  the  result.  Persisting  in  a 
disk-shaped  area,  as  in  man,  a  discoidal  placenta  is  formed. 

Fetal  Membranes  in  Man. — The  development  of  the  human  ovum 
prior  to  the  stage  in  which  the  amniotic  cavity  and  yolk  cavity  are 
already  present  is  unknown.  However,  the  conditions  in  the  youngest 
human  ovum  so  closely  resemble  those  at  a  corresponding  stage  in  some 
of  the  lower  mammals  in  which  previous  development  has  been  studied 
that  we  may  infer  at  least  a  similarity  in  the  antecedent  processes  in 
man. 

In  those  mammals  in  which  the  processes  have  been  studied,  seg- 
mentation results  in  a  solid  mass  of  cells,  the  morula  (Fig.  48).  The 
superficial  cells  of  the  morula  are  differentiated  from  those  in  the  interior 
to  form  the  covering  layer  which  subsequently  becomes  the  chorionic 
ectoderm  or  trophoderm  (Fig.  50).  Most  of  the  central  cells  then 
become  vacuolated  and  the  vacuoles  coalesce  to  form  the  yolk  cavity, 
a  few  cells  remaining  attached  to  the  covering  layer  as  the  inner  cell 
mass  (Fig.  52).  From  this  point  on  the  development  of  the  bat's  ovum 
may  be  taken  to  represent  the  stages  in  the  human  ovum  up  to  the 
earliest  condition  known.  In  the  bat,  following  the  formation  of  the  yolk 
cavity,  those  cells  of  the  inner  cell  mass  bordering  upon  the  cavity  dif- 
ferentiate and  spread  out  in  a  single  layer  or  lining  which  represents  the 
primitive  entoderm  (Fig.  53).  In  the  meantime  the  interior  of  the 
inner  cell  mass  becomes  vacuolated,  thus  forming  the  amniotic  cavity 
which  is  separated  from  the  yolk  cavity  by  the  embryonic  disk.  The 
disk  is  composed  of  entoderm  and  a  single  layer  of  cells  of  the  inner  cell 
mass.  This  layer  is  continuous  at  its  margin  with  the  roof  of  the  amniotic 
cavity  (Fig.  55).  The  next  step  in  development  is  the  appearance 
of  mesoderm  everywhere  between  the  covering  layer  and  entoderm, 
between  the  covering  layer  and  roof  of  the  amniotic  cavity  and  between 
the  ectoderm  and  entoderm  in  the  embryonic  disk.  In  general  the 
conditions  now  resemble  those  in  the  earliest  known  human  ovum,  which 
has  been  described  by  Bryce  and  Teacher  and  estimated  by  them  to  be 
between  thirteen  and  fourteen  days  old. 

The  Bryce-Teacher  ovum  is  represented  in  section  in  Fig.  72.  The 
outer  layer,  exhibiting  many  irregular  projections  which  will  be  con- 
sidered in  detail  subsequently,  is  the  trophoderm.  In  the  interior  of  the 
chorionic  vesicle,  or  blastocyst  (names  which  have  been  given  to  the 
entire  structure)  are  two  cavities,  the  larger  being  the  amniotic,  lined 
with  ectoderm,  and  the  smaller  representing  the  yolk  cavity,  lined  with 
entoderm.  Mesoderm  of  a  very  loose  texture  fills  the  space  between 
the  two  cavities  and  the  trophoderm. 

In  Fig.  73  is  represented  a  section  of  an  ovum  described  by  Peters 
and  now  reckoned  to  be  fourteen  or  fifteen  days  old.  Here  again  the 
trophoderm  is  seen  to  extend  in  all  directions  in  irregular  projections, 
and  the  mesoderm  has  begun  to  invade  the  trophoderm,  thus  forming 
rudimentary  villi.  Within  the  chorionic  vesicle  the  mesoderm  is  divided 
into  two  layers.  The  outer  or  parietal  layer  is  apposed  to  the  tropho- 
derm and  together  with  the  latter  constitutes  the  chorion  proper.    The 


92 


EMBRYOLOGY  AND  PHYSIOLOGY 


iiiiior  or  visctTul  layer  is  api)lie(l  to  the  entoderm  of  the  yolk  sac. 
The  space  between  the  parietal  and  visceral  mesoderm  is  the  extra- 
embryonic body  cavity.  The  roof  of  the  amniotic  cavity  is  still  fused 
with  the  chorion. 

A  longitudinal  section  of  an  embryo  2  millimeters  in  length,  described 
by  von  Spee,  is  shown  in  Fig.  74,  while  Fig.  75  represents  a  dorsal 
view  of  the  same  embryo  in  toto.  It  will  be  noted  that  the  amnion  has 
split  away  from  the  chorion  except  at  the  caudal  end  of  the  embryo, 
where  a  cord  of  mesoderm — the  belly  stalk — still  serves  to  attach  the 


cyt. 


cyt. 


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!j«-l»***>KRSlr''^WSi5iBi|    e.p. 


."•vfS^v 


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V/^•'^;-.•.'N.>v;^.^ 

ri' 

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iro'. 


Fig.  72. — Diagram  of  human  ovum  of  thirteen  or  fourteen  days,  embedded  in  the  uterine 
mucosa:  cap.,  capillary;  cyt.,  cellular  layer  (cyto-trophoderm) ;  e.p.,  uterine  epithelium; 
gl.,  uterine  gland;  n.z.,  necrotic  zone  of  decidua  (uterine  mucosa);  P.e.,  point  of  entrance 
of  the  ovum;  tro.,  syncytium  (plasmodium,  plasmodi-trophoderm) ;  tro'.,  masses  of  vacuolat- 
ing syncytium  invading  capillaries.  The  cavity  of  the  blastodermic  vesicles  is  completely 
filled  by  mesoderm,  and  embedded  therein  are  the  amniotic  and  entodermic  (yolk)  vesicles. 
The  natural  proportions  of  the  several  parts  have  been  observed.      (Bryce  and  Teacher.) 


amnion  and  embryo  proper  to  the  chorion.  The  allantois  is  a  slender 
diverticulum  of  entoderm  which  grows  into  the  belly  stalk.  At  the 
cephalic  end  a  slight  constriction  already  marks  the  boundary  between 
the  embryo  and  the  yolk  sac.  All  the  rudiments,  therefore,  of  the  fetal 
membranes  are  present. 

The  Amnion. — While  the  amniotic  cavity  and  amnion  in  man  prob- 
ably originate  through  vacuolization  of  the  inner  cell  mass,  a  process 
quite  different  from  the  folding  of  the  somatopleure  as  described  in 
some  of  the  other  mammals  (c/.   Fig.  71),  their   further  development 


FETAL  MEMBRANES 


9'. 


is  essentially  the  same  as  in  the  other  forms  (cf.  Fig.  71).    At  first  small 
and  covering  only  the  dorsum  of  the  embryo,  the  amnion  increases 


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rapidly  in  size  and  envelops  the  Avhole  embryo  as  the   latter  is   con- 
stricted from  the  volk  sac.    Bv  the  end  of  the  second  month  it  obliterates 


94 


EMBRYOLOGY  AXD   PHYSIOLOGY 


Chorionic  villi 


"IT--— --Chorion 

_  Mesoderm 
^  of  chorion 

-liellv  Stalk 


Primitive  streak 
Allantois 


Mesoderm 
of  yolk  sac 


h — Blood  vessel 


Fig.  74. — Medial  section  of  human  embryo  2  mm.  in  length.     {Cf.  Fig.  75.)     (Von  Spoe.) 


Yolk-sac 


Amnion 


Neural  groove 


Neureyiteric  canal 

Primitive  streak 
Body-stalk 


Fig.  75. — Human  embrj^o — length,  2  mm.    Dorsal  ^aew,  with  the  amnion  laid  open.      X  30. 

(After  von  Spee.) 


FETAL  MEMBRANES 


95 


the  extra-embryonic  body  cavity  and  fuses  with  the  mesodermal  layer 
of  the  chorion,  although  not  so  firmly  but  that  even  at  birth  it  can  easily 
be  separated  as  a  transparent,  glistening  membrane.  Bloodvessels  are 
lacking  in  the  amnion.  The  amniotic  cavity  becomes  filled  with  liquor 
amnii,  a  watery  fluid  of  slightly  alkaline  reaction  and  containing  about 
1  per  cent,  of  solids.  The  fluid,  which  amounts  to  about  1  liter  at  the 
end  of  pregnancy,  is  probably  secreted  by  the  amniotic  epithelium,  the 


X 


Fig.  76. — Human  embryo  of  2.6  mm.,  with  amnion  and  yolk  sac.  The  amnion  closely 
invests  the  embryo.  1,  belly  stalk;  2,  heart;  3,  vitelline  vein;  4,  vitelline  artery;  5,  yolk  sac. 
(His,  Kollmann's  Atlas.) 


evacuations  of  the  fetal  urinary  bladder  being  inconsiderable.  The 
functions  of  the  liquor  amnii  are  important:  (a)  It  serves  as  a  water 
supply  for  the  fetus,  both  by  absorption  through  the  skin,  especially  dur- 
ing the  early  months,  and  by  swallowing.  The  latter  is  proved  by  find- 
ing in  the  intestinal  canal  of  the  fetus  epidermal  cells,  hairs  and  portions 
of  vernix  caseosa  which  could  have  reached  there  only  by  being  swallowed 
with  some  of  the  liquor  amnii.  The  amount  of  solid  matter,  however, 
in  the  amniotic  fluid  is  so  slight  (1  or  2  per  cent.)  that  its  nutritive 


96 


EMBRYOLOGY  AND  PHYSIOLOGY 


value  must  be  regarded  as  slight,  (b)  It  serves  as  a  protection  to  the 
fetus  against  blows,  falls,  pressure  or  other  injury,  (c)  It  allows  free- 
dom of  motion,  thus  favoring  muscular  development,  (d)  It  serves  to 
maintain  a  constant  temperature,  (e)  Enclosed  in  the  amnion  it  serves 
as  a  fluid  wedge  in  the  gradual  dilatation  of  the  cervix,  a  function  which 
human  art,  by  elastic  bags,  has  often  tried  to  imitate  but  never  equalled. 
The  yolk  sac  in  the  human  embryo  is  but  a  rudiment  of  the  large 
and  important  structure,  full  of  nutriment,  found  especially  in  reptiles 
and  birds  and  also  in  some  of  the  still  lower  forms.  The  mesoderm  in 
the  wall  does  serve,  however,  in  the  mammalian  forms,  including  man,  as 


Gut 


Umbilical  vein 


Amnion 


Allantois 


Yolli  stalk 


Umbilical  artery 
Umbilical  vein 

Anmion 


Chorionic  villi 


Fig.  77. 


-Diagram  of  the  umbilical  vessels  in  the  belly  stalk  and  chorion. 

Atlas.) 


(Kollmann's 


an  important  blood-forming  organ  in  early  embryonic  life,  and  an  exten- 
sive vitelline  circulation  is  established,  which  atrophies,  however,  with 
the  subsequent  regressive  changes  in  the  sac.  During  the  third  week 
a  decided  constriction  occurs  between  the  sac  and  the  embryo  (Fig.  76). 
The  sac  remains  for  a  time  attached  to  the  intestine  by  a  pedicle,  the 
yolk  stalk,  which  is  embedded  in  the  umbilical  cord.  The  yolk  stalk 
eventually  disa]>pears  and  the  sac  itself,  as  the  amnion  enlarges,  is  car- 
ried away  from  the  embryo.  At  birth  the  yolk  sac  can  usually  be  found 
between  the  amnion  and  chorion  on  the  placenta  near  the  attachment 
of  the  umbilical  cord,  sometimes  on  the  chorion  \^^eve.     It  is  a  white  or 


■       FETAL  MEMBRANES  97 

yellow  body,  round  or  oval,  somewhat  flattened,  with  a  diameter  of 
1  to  5  millimeters.    Its  contents  may  be  partly  calcified. 

The  Allantois. — It  has  been  noted  that  the  allantois  grows  into  the 
belly  stalk  as  a  slender  entodermal  diverticulum  composed  of  cuboidal 
cells  and  often  called  the  allantoic  duct  (Fig.  74).  This  rudimentary 
structure  contrasts  sharply  with  the  much  larger  sac-like  allantois  in 
lower  forms  (especially  birds  and  reptiles),  where  it  serves  as  a  reservoir 
for  waste  products  of  the  embryo  and  in  part  as  an  organ  of  respiration. 
Its  rudimentary  character  in  man  and  mammals  in  general  is  due  to 
the  intimate  relationship  established  between  the  embryo  and  maternal 
tissues,  in  which  case  the  excretions  are  transmitted  to  the  maternal 
blood.  The  allantoic  (or  umbilical)  bloodvessels,  however,  since  they 
extend  through  the  belly  stalk  to  the  chorion  (Fig.  77)  assume  prime 
importance  in  that  they  not  only  convey  waste  products  to  the  maternal 
blood  but  also  carry  nutritive  substances  back  to  the  embryo.  The 
allantoic  duct  usually  remains  hollow  in  embryos  up  to  8  or  9  millimeters 
in  length.  It  then  begins  to  atrophy.  In  the  fourth  month  portions  of 
it,  containing  lumina,  may  still  be  found;  and  even  in  the  mature  um- 
bilical cord  occasional  epithelial  pearls  persist  as  remnants  of  the  duct. 
The  portion  of  the  allantoic  duct  within  the  embryo,  extending 
from  the  apex  of  the  bladder  to  the  umbilicus,  is  known  as  the 
urachus. 

Implantation  of  the  Ovum. — The  Chorion  and  Decidua. — Nothing 
is  known  concerning  the  behavior  of  the  human  ovum  from  the  time 
it  escapes  from  the  Graafian  follicle  until  it  becomes  embedded  in  the 
uterine  mucosa.  From  conditions  in  lower  mammals  it  is  inferred  that 
the  ovum,  escaping  from  its  follicle  and  entering  the  fimbriated  end  of 
the  Fallopian  tube,  is  fertilized  in  the  outer  third  of  the  tube;  that  it 
then  passes  on  through  the  tube  into  the  uterus,  the  movement  being 
due  to  the  action  of  the  cilia  on  the  epithelium  lining  the  tube  and  uterus; 
and  that  during  this  passage  it  loses  its  zona  pellucida  and  corona  radiata 
and  undergoes  the  early  processes  of  development  (segmentation  and 
beginning  formation  of  the  germ  layers),  probably  deriving  oxygen  and 
nourishment  from  the  secretions  of  the  mucous  membrane.  The  time 
occupied  by  the  ovum  in  traversing  the  distance  to  the  point  of  implan- 
tation in  the  uterus  has  been  estimated  at  seven  or  eight  days. 

By  implantation  is  meant  the  processes  by  which  the  ovum,  or  blasto- 
cyst, becomes  embedded  in  the  mucous  membrane  of  the  uterus.  The 
generally  accepted  view  is  that  the  ovum  penetrates  the  mucosa  like  a 
parasite  through  an  opening  which  it  makes  for  itself.  The  maternal 
tissues  are  probably  dissolved  by  the  action  of  ferments  secreted  by  the 
trophoderm.  The  ferments  affect  not  only  the  epithelium  but  the  con- 
nective tissue  and  endothelium  of  the  bloodvessels  of  the  stroma.  The 
cavity  thus  formed  in  the  mucous  membrane  of  the  uterus  therefore 
contains  the  blastocyst  and  a  large  amount  of  maternal  blood  which  has 
escaped  from  the  invaded  vessels  (Fig.  72).  The  invasion  of  the  mater- 
nal bloodvessels  by  the  trophoderm  results  in  the  essential  character 
of  a  placenta  of  the  hemochorialis  t}npe  (see  p.  90),  namely,  that  the 
7 


98  EMBRYOLOGY  AND  PHYSIOLOGY 

superficial  embryonic  tissue   (chorionic  ectoderm,  trophoderm)   comes 
in  direct  contact  with  the  maternal  blood. 

Implantation  usually  occurs  either  on  the  posterior  or  anterior  wall 
of  the  uterus  and  determines  the  situation  of  the  placenta.  It  probably 
does  not  take  place  in  a  gland  but  between  glands.  The  cause  of  pene- 
tration of  the  uterine  mucosa  by  the  ovum  remains  undetermined.  It 
is  assumed,  however,  that  ameboid  activity  of  the  superficial  cells  of 
the  trophoderm  is  at  least  one  of  the  prime  factors. 

Regarding  the  time  of  implantation,  obstetric  experience  seems  to 
indicate  that  fertilization  of  the  human  ovum  is  most  likely  to  occur 
in  the  week  following  menstruation  and  the  Naegele  rule  for  estimating 
the  probable  date  of  confinement,  the  rule  followed  at  the  Sloane  Hos- 
pital, is  based  on  this  fact.  Bryce  and  Teacher  claim  that  fertilization 
of  the  ovum  in  the  Fallopian  tube  exercises  an  inhibiting  effect  upon  the 
premenstrual  changes  in  the  uterine  mucosa;  otherwise  menstruation 
would  continue  through  early  pregnancy. 

The  time  elapsing  between  fertilization  and  implantation  is  not  known. 
The  Bryce-Teacher  ovum,  estimated  to  be  thirteen  or  fourteen  days 
old,  was  already  perfectly  embedded,  and  we  may  infer  that  the  pro- 
cess occurs  before  the  end  of  the  second  Aveek.  It  has  also  been  esti- 
mated that  the  time  required  for  the  fertilized  ovum  to  pass  through 
the  tube  is  from  seven  to  eight  days.  Implantation  would  therefore 
occur  between  the  eighth  and  thirteenth  days. 

The  Chorion  and  Deciduse. — As  soon  as  the  ovum  becomes  embedded 
in  the  uterine  mucosa  the  latter  can  be  divided  into  three  parts  in  rela- 
tion to  the  ovum:  (1)  a  part  beneath  the  ovum,  (2)  a  part  between  the 
ovum  and  the  cavity  of  the  uterus,  and  (3)  the  region  exclusive  of  these 
two.  Much  of  the  mucosa  of  pregnancy  is  cast  off  at  birth  as  the  decidua. 
The  three  parts  mentioned  above  are  therefore  named  (1)  decidua 
basalis  (serotina),  (2)  decidua  capsularis  (reflexa)  and  (3)  decidua  parie- 
talis  (vera)  (see  Fig.  78).  It  has  been  previously  stated  (p.  90)  that 
villi  at  first  develop  over  the  entire  surface  of  the  chorion  and  that  sub- 
sequently the  great  majority  of  these  atrophy  and  disappear.  The 
portion  of  the  chorion  over  which  they  disappear  constitutes  the  chorion 
Iseve  and  is  associated  principally  with  the  decidua  capsularis  (Fig.  78). 
The  portion  on  which  they  continue  to  develop  is  associated  with  the 
decidua  basalis  and  forms  the  chorion  frondosum.  The  decidua  basalis 
and  chorion  frondosum  together  form  the  placenta,  which  is  thus  made 
up  of  a  maternal  portion  and  a  fetal  portion  (Fig.  78). 

The  Decidua  Basalis. — It  has  been  seen  that  the  Bryce-Teacher  ovum 
exhibits  numerous  irregular  projections  of  the  trophoderm  (Fig.  72). 
The  destructive  or  digestive  action  of  the  trophoderm  on  the  uterine 
mucosa  results  in  the  relatively  large  implantation  cavity.  It  is  held  by 
some  investigators  that  the  action  is  phagocytic.  The  condition  of  the 
zone  of  mucosa  immediateh'  surrounding  the  implantation  cavity  in 
the  Bryce-Teacher  ovum  would  indicate,  however,  that  the  destruction 
of  maternal  tissue  is  brought  about  by  the  action  of  some  substance  of 
the  nature  of  a  ferment  elaborated  by  the  trophoderm  rather  than  by 


FETAL  MEMBRANES 


99 


phagocytic  action.  This  coincides  with  the  well-supported  view  that 
the  ovum  first  becomes  embedded  in  the  mucosa  through  the  action 
of  ferments  (p.  97).  The  destructive  action  of  the  trophoderm  extends 
to  the  walls  of  the  maternal  bloodvessels,  and  the  blood,  escaping  from 
the  vessels,  fills  the  implantation  cavity  and  thus  bathes  the  surface  of 
the  chorion.  This  intimate  relation  between  maternal  blood  and  chor- 
ion is  of  prime  importance  in  nourishing  the  rapidly  growing  embryo. 
Of  much  interest  and  importance  is  the  fact  that  the  extravasated  mater- 
nal blood  does  not  coagulate  while  in  contact  with  the  trophoderm.  The 
trophoderm  apparently  acts  in  this  respect  as  the  living  endothelium. 


Fig.  78. — Semidiagrammatic  outline  of  an  anteroposterior  section  of  the  gravid  uterus 
and  ovum  of  five  weeks:  a,  anterior  uterine  wall;  b,  posterior  uterine  wall;  c,  decidua  vera 
(parietalis) ;  d,  decidua  reflexa  (capsularis) ;  e,  decidua  serotina  (basalis) ;  ch,  chorion  with  its 
villi.     (Jewett,  modified  from  Allen  Thomson.) 

The  chorion  frondosum,  associated  with  the  decidua  basalis,  is  char- 
acterized by  profuse  growth  of  the  chorionic  villi.  These  structures  arise 
through  invasion  of  the  primary,  irregular  trophodermic  projections  by 
the  chorionic  mesoderm,  each  villus  thus  being  composed  of  a  core  of 
mesoderm  and  an  outer  layer  of  trophoderm  (Fig.  73).  They  grow 
rapidly  and  branch  freely,  forming  complex  tree-like  structures  (Fig. 
79).  Some  of  the  branches  become  firmly  attached  to  the  decidua 
basalis  and  are  known  as  anchoring  villi.  The  majority  of  the  branches 
end  free  in  the  maternal  blood  sinuses  as  floating  or  terminal  villi  (Fig. 


100 


EMBRYOLOGY  AND  PHYSIOLOGY 


80).  The  villi  are  divided  into  groups  by  partitions  of  the  decidua 
basalis  (Figs.  SO,  81,  and  82).  These  groups,  corresponding  to  the  lobes 
of  an  ordinary  gland,  are  known  as  cotyledons  and  the  partitions  as 
placental  septa. 


Fig.  79. — Isolated  villi  from  chorion  frondosum  of  a  human  embryo  of  eight  weeks 
1,  decidua;  2,  anchoring  villi;  3,  terminal  villi;  4.,  chorion;  5,  artery;  6,  vein;  7,  chorion.' 
(Kollmann's  Atlas.) 

The  mesodermal  core  of  the  chorionic  villus  at  first  comprises  a  loose, 
fibrous  connective  tissue  which,  during  the  second  month  of  gestation, 
becomes  vascularized  by  branches  of  the  allantoic  (umbilical)  vessels. 
As  development  proceeds  the  connective  tissue  becomes  denser  and 
toward  the  end  of  pregnancy  the  intercellular  sulistance  assumes  a 
hyaloid  character.  The  tro|)hoderm  early  undergoes  difl'erentiation 
into  two  layers.     The  inner  layer,  apposed  to  the  mesoderm,  exhibits 


FETAL  MEMBRANES 


101 


fairly  distinct  cell  boundaries  and  is  known  as  the  cellular  layer  (of 
Langhans)  or  cytotrophoderm.     The  outer  layer,  in  contact  with  the 


Fig.  80. — Diagrammatic  section  of  placenta.     (Strahl,  Bonnet.) 

maternal  blood,  exhibits  no  cell  boundaries  and  is  known  as  the  syncytial 
layer,  or  plasmoditrophoderm.     The  cj^oplasm  of  the  inner  layer  is 


Umbilical  cord 


Chorion  laeve 


7  jfr^ 

f  y 


Cotyledon 


s 


\ 


/  . 


<\ 


—"i 


Decidua  basalis 


Cotyledon 


Fig.  81. — -Mature  placenta,  from  maternal  side.      (Bonnet.) 


granular  and  shades  off  into  the  homogeneous  cytoplasm  of  the  outer 
layer  (Fig.  83).  ^    • 


102 


EMBRYOLOGY  AND  PHYSIOLOGY 


The  intervillous  spaces  represent  l)lood  sinuses  which  are  derixed 
from  the  vessels  of  the  mucous  membrane  of  the  uterus  through  disso- 
lution of  their  walls,  and  are  destitute  of  endotheliiun.  They  are  filled 
with  slowly  circulating  maternal  blood  wliich  enters  through  the  arteries 
of  the  uterine  wall  and  leaves  through  the  corresponding  veins  (Fig.  80). 
At  the  border  of  the  placenta  is  the  marginal  sinus,  usually  not  invaded 
by  villi,  which  is  separated  from  the  chorion  itself  by  a  closing  plate  of 


Fig.  82. 


-Mature  placenta,  seen  from  the  maternal  side,  showing  the  umbilical  cord  and 
the  placental  lobes  or  cotyledons.     (Photograph.) 


maternal  tissue  (Fig.  80).  There  is  never  normally  any  mingling  of 
the  maternal  with  the  fetal  blood,  the  blood  in  the  intervillous  spaces 
(maternal  sinuses)  being  separated  from  that  in  the  core  of  the  villus 
by  trophoderm,  connective  tissue  of  the  villus  and  endothelium  of  the 
fetal  vessel  wall. 

During  the  first  month  of  pregnancy  the  trophoderm  on  some  parts 
of  the  villi  begins  to  proliferate  with  great  rapidity,  resulting  in  large 


FETAL  MEMBRANES 


103 


masses  of  cells  which  project  into  the  intervillous  spaces  (Fig.  84). 
Whether  the  proliferation  involves  the  cellular  layer  or  the  syncytial 
layer,  or  both,  has  not  been  determined.  Whatever  the  origin  of  these 
masses,  the  cell  bovmdaries  are  usually  distinct.  In  some  regions  the 
cells  are  small  and  granular,  with  densely  staining  nuclei,  and  in  other 
regions  the  cells  are  large  and  homogeneous,  with  large  vesicular  nuclei; 
and  every  gradation  between  these  two  extremes  can  be  seen.  Large 
multinuclear  cells  or  giant  cells  also  appear  (Fig.  84).  They  appar- 
ently lie  free  in  the  intervillous  spaces,  although  it  is  generally  claimed 
that  they  represent  sections  of  tips  of  the  syncytial  layer. 

Soon  after  the  masses  of  trophoderm  appear  they  begin  to  undergo 
degenerative  changes  which  lead  to  the  formation  of  a  structure  known 


Fig.  83. — Transverse  section  of  a  chorionic  villus  from  a  human  embryo  of  two  months, 
showing  mesodermal  core  surrounded  by  the  cellular  and  syncytial  layers  of  trophoderm: 
1,  Hofbauer's  cell;  £,  capillary.      (Grosser.) 

as  canalized  "fibrin"  (Fig.  84).  While  this  is  not  fibrin  in  the  true 
sense,  it  nevertheless  is  acidophilic  and  in  sections  stained  with  eosin 
can  be  recognized  by  its  brilliant  red  appearance. 

In  the  later  months  of  pregnancy  the  covering  layer  of  the  villi  is 
reduced  to  a  thin  homogeneous  membrane.  The  cellular  layer  (cyto- 
trophoderm)  disappears  and  the  syncytial  layer  (plasmoditrophoderm) 
forms  the  thin  membrane.  At  points  in  this  membrane  are  knob-like 
projections  composed  almost  wholly  of  densely  staining  nuclei  (Fig.  85). 

Another  important  type  of  cell  is  found  not  only  in  the  decidua  but 
also  in  the  neighboring  portions  of  the  uterine  wall.  These  are  the 
decidual  cells  and,  although  considerable  controversy  has  arisen  over 
their  origin,  it  has  been  well  established  that  they  represent  modified 


104 


EMBRYOLOGY  AND  PHYSIOLOGY 


connective-tissue  cells  of  the  uterine  stroma.  They  are  large  (30  to  100 
microns  in  diameter)  and  vary  in  shape.  Late  in  pregnancy  they  acquire 
a  brownish  pigment  which,  owing  to  the  great  number  of  cells,  gives  the 


^,, 


ir?«s'- 


'  '<« 


r^;|M 


Fig.  84. — Section  of  human  chorion  of  one  month:    1,  giauL  Leil;    ^,  wyucytium;    5,  tro- 
phoderm  mass;  4>  syncytium;  5,  canalized  "fibrin";  6,  stroma  of  villus.     (Grosser.) 


Remnant  of  syncytium 
Capillaries  *■ 


.Nucleai 
groups 


Remnant 
■  of  syncytium 


f Capillary 

Nuclear  group 
Fig.  85. — Transver.se  sections  of  chorionic  villi  at  the  end  of  pregnancy.      (Schaper.) 

brownish  color  to  the  superficial  layer  of  the  decidua.  Each  cell  usually 
contains  a  single  large  vesicular  nucleus;  occasionally  multinucleated 
cells  are  seen.     These  decidual  cells  are  related  not  only  as  to  their 


FETAL  MEMBRANES  105 

origin  but  also  as  to  their  general  characters  to  the  decidual  cells  of 
the  menstruating  mucosa  (p.  83). 

The  portion  of  the  uterine  mucosa  beneath  the  chorionic  villi  can  be 
divided  into  two  layers:  (1)  a  compact  layer  of  connective  tissue  which 
gives  off  the  placental  septa  and  to  which  the  anchoring  \-illi  are  attached, 
and  (2)  a  spongy  layer  between  this  and  the  muscularis  which  contains 
the  flattened  remnants  of  a  few  uterine  glands  lying  parallel  to  the 
muscularis.  x\s  will  be  noted  subsequently  the  line  of  separation  of  the 
decidua  at  parturition  passes  through  the  spong}'  layer. 

The  Decidua  Parietalis. — The  changes  in  the  uterine  mucosa  which 
result  in  the  formation  of  the  decidua  parietalis  resemble  those  which 
occur  during  the  premenstrual  period.  These  changes  comprise  mainly 
an  increase  in  size  and  tortuosity  of  the  glands,  congestion  of  the  stroma, 
and  proliferation  of  its  connective-tissue  cells.  The  resulting  thicken- 
ing of  the  mucosa  extends  to  the  internal  os  where  it  ends  abruptly, 
no  decidua  being  formed  in  the  cervix. 

In  the  superficial  part  of  the  mucosa  the  glands  disappear,  and  the 
connective  tissue  here  forms  a  dense  sheet  known  as  the  compact  layer. 
Beneath  this  are  found  remains  of  uterine  glands  in  the  form  of  tortuous 
spaces  extending  mostly  parallel  to  the  muscularis.  Some  of  these 
glandular  structures  lose  much  of  their  epithelium.  Lying  in  the  stroma, 
these  spaces  give  to  this  portion  of  the  mucosa  the  structure  which  has 
led  to  the  designation,  spongy  layer. 

During  the  latter  half  of  pregnancy  the  decidua  parietalis  becomes 
markedly  thinner,  owing  to  pressure  from  the  growing  embryo  and  its 
membranes.  The  glands  in  the  spongy  layer  collapse  and  are  reduced 
to  slit-like  spaces  parallel  to  the  muscularis.  The  tissue  in  general 
becomes  much  less  vascular  than  in  early  pregnancy. 

The  Decidua  Capsularis. — The  older  name,  decidua  reflexa,  indicates 
the  earlier  view  that  this  portion  of  the  decidua  represented  a  portion  of 
the  uterine  mucosa  which  grew  around  the  attached  ovum.  The  later 
researches  have  shown  that  the  ovum  buries  itself  in  the  uterine  mucosa 
(p.  97)  and  that  the  portion  of  mucous  membrane  between  the  ovum 
and  the  cavity  of  the  uterus  as  the  ovum  and  its  membrane  continue 
to  grow  constitutes  the  decidua  capsularis  (see  Figs.  72  and  78).  Early 
in  development  it  exhibits  essentially  the  same  structure  as  the  decidua 
basalis.  By  about  the  fifth  month  the  rapidly  growing  embryo  with 
its  membranes  fills  the  uterine  cavity  and  the  decidua  capsularis,  now 
but  a  thin  transparent  membrane,  is  pressed  against  the  decidua  parie- 
talis, and,  according  to  some  investigators,  eventually  disappears  or,  as 
held  by  others,  fuses  with  the  parietalis.  The  portion  of  the  chorion  on 
which  the  villi  ultimately  disappear,  namely,  the  chorion  Iseve  (p.  98), 
is  always  associated  with  the  decidua  capsularis.  The  amnion  in  turn 
is  fused  with  the  chorion  Iseve  as  with  the  chorion  frondosum  (p.  98). 
The  amnion  and  chorion  laeve  together,  in  the  later  months  of  preg- 
nancy, form  therefore  but  a  thin  membrane  which  (in  case  the  decidua 
capsularis  disappears)  is  applied  to  the  decidua  parietalis. 

At  parturition  the  Hne  of  separation  of  the  deciduse  from  the  uterine 


106  EMBRYOLOGY  AND  PHYSIOLOGY 

wall  passes  through  the  deeper  part  of  the  spongy  layer  (see  Fig.  80). 
By  this  separation  many  of  the  larger  maternal  bloodvessels  are  opened, 
but  hemorrhage  is  held  in  check  by  the  firm  contraction  of  the  uterine 
muscle.  The  condition  of  the  uterine  mucosa  after  childbirth  has 
been  described  as  an  exaggeration  of  its  condition  at  the  height  of  the 
menstrual  period.  Reconstruction  of  the  mucosa  takes  place  through 
proliferation  and  rearrangement  of  the  remaining  glandular  elements  and 
connective  tissue. 

The  Placenta. — From  the  preceding  study  it  is  seen  that  the  placenta 
is  a  spongy  discoid  mass  formed  during  the  latter  part  of  the  third  month 
of  pregnancy  by  the  union  of  the  decidua  basalis  and  the  chorion  fron- 
dosimi ;  that  it  is  covered  on  its  fetal  surface  by  the  amnion  and  is  attached 
by  its  outer  surface  to  the  wall  of  the  uterus,  usually  at  its  upper  part. 
The  placenta  is  thus  seen  to  consist  of  both  a  maternal  and  a  fetal 
portion.  Through  the  umbilical  cord  it  is  attached  to  the  fetus  at  its 
umbilicus. 

The  Placenta  at  Term. — Examination  of  the  placentae  of  1000  consecu- 
tive, normal  full-term  deliveries  at  the  Sloane  Hospital  gave  the  following 
results:  The  average  weight  was  651.92  grams;  approximately  23  ounces. 
The  average  diameters  were  19.14  cm.  x  17.14  cm.  The  placenta  near 
its  centre  measures  from  3  to  4  cm.  in  thickness,  gradually  thinning  toward 
its  circumference.  As  seen  in  Fig.  82,  the  maternal  surface  is  rough, 
covered  by  a  thin,  soft  layer  of  decidua  which  in  the  cleavage  of  the 
decidua  basalis  has  remained  attached  to  the  chorion  and  has  separated 
from  the  uterus.  By  grooves  formed  by  the  indipping  of  septa  of  the 
decidua  basalis  the  maternal  surface  is  divided  into  irregular  lobes 
or  cotyledons  1  to  3  cm.  in  diameter.  It  is  of  a  beefy-red  color  and  shows 
torn  shreds  of  maternal  bloodvessels.  The  inner  or  fetal  surface  of  the 
placenta  (Fig.  86)  is  smooth,  glistening  and  pearl-colored.  It  is  covered 
by  the  amnion  through  which  are  distinctly  seen  the  branches  of  the 
umbilical  arteries  and  vein  converging  to  the  umbilical  cord,  which 
usually  leaves  the  placenta  eccentrically.  The  amnion  can  readily' 
be  peeled  off  from  the  fetal  surface  of  the  placenta  as  a  thin,  almost 
transparent,  membrane. 

A  section  through  the  substance  of  a  normal  placenta,  when  viewed 
microscopically  (Fig.  87),  shows  the  field  studded  with  chorionic  villi 
cut  at  different  angles,  transversely,  longitudinally  and  obliquely.  The 
structure  of  these  villi  has  already  been  described  when  discussing  the 
chorion  frondosum. 

The  Functions  of  the  Placenta. — Aside  from  the  transmission  of  oxygen 
and  nutrition  from  the  maternal  to  the  fetal  blood  the  placenta  also 
serves  as  an  organ  of  excretion,  as  here  not  only  CO2  but  other  waste 
products  of  fetal  metabolism  pass  from  fetal  to  maternal  blood.  It 
thus  serves  as  the  organ  of  mutual  exchange;  absorbing  that  which  is 
necessary  to  fetal  existence  and  getting  rid  of  excrementitious  substances 
deleterious  to  fetal  life.  The  villi  also  seem  to  have  certain  selective 
powers,  as  some  drugs  pass  readily  from  maternal  to  fetal  blood  while 
others  will  not. 


FETAL  MEMBRANES 


107 


Pathology  of  the  Placenta. — The  unusual  and  pathological  conditions 
of  the  placenta  may  be  conveniently  grouped  as  follows:  (1)  Abnor- 
malities of  form  and  size,  (2)  degenerations,  (3)  diseases,  and  (4)  neoplasms. 

1.  Abnormalities  of  Form  and  Size. — Occasionally  there  is  an  aperture 
in  the  placenta  (placenta  fenestrata).  Sometimes  the  organ  is  incom- 
pletely divided  into  two  parts  (placenta  bipartita).  In  some  instances 
there  is  a  complete  separation  into  two,  three  or  more  distinct  lobes 


Fig.  86. — Mature  placenta,  seen  from  the  fetal  side.     (Photograph.) 

(placenta  duplex,  triplex,  or  muliplex).  In  very  rare  cases  the  placenta, 
in  the  form  of  a  relatively  thin  structure,  is  adherent  to  the  entire  interior 
of  the  uterus  (placenta  membranacea) .  Not  infrequently  a  single  coty- 
ledon or  a  group  of  cotyledons  appears  as  a  separate  lobule  connected 
with  the  main  organ  by  branches  of  the  umbilical  vessels  (placenta 
succenturiata) . 

The  causes  underlying  these  unusual  forms  are  not  clear.    It  has  been 
assumed,  and  not  without  reason,  that  the  portion  of  the  chorion  which 


lOS 


EMBRYOLOGY  AND  PHYSIOLOGY 


Fig.  87.— Vertical  section  of  the  human  placenta,  about  the  seventh  month  in  situ. 
X  6.  Am.,  amnion;  Cho.,  chorion;  Vi.,  villous  trunk:  m.,  sections  of  villi  in  the  substance  of 
the  placenta;  D  ,  Z>",  dccidua  basalis;  Mc,  muscularis;  Ve..  uterine  artery  opening  into 
placenta;  the  fetal  bloodvessels  arc  drawn  black,  the  maternal  bloodvessels  white-  the 
chorionic  tissue  is  stippled,  except  the  canaHzed  fibrin,  which  is  shaded  by  lines;  remAants 
ot  the  gland  cavities  in  the  decidua  are  stippled  dark.     (Minot  ) 


FETAL  MEMBRANES  109 

de\-elops  into  the  fetal  part  of  the  placenta  is  very  largely  influenced, 
as  regards  its  shape  and  attachment  to  the  uterine  wall,  by  the  distribu- 
tion of  the  decidual  bloodvessels.  The  varieties  in  form  and  size  of  the 
placenta  in  multiple  pregnancy  are  shown  and  discussed  under  that  head 
(see  page  195). 

2.  Degenerations. — X  certain  constant  type  of  degeneration  of  the 
trophoderm  has  already  been  mentioned  (page  103).  In  addition  to  this 
other  degenerative  changes  occur  in  every  placenta.  The  chief  factor 
in  bringing  about  these  changes  appears  to  be  a  deranged  blood  supply 
due  to  fibrosis  of  the  vessel  walls  in  the  villi.  With  the  narrowing  and 
obliteration  of  the  lumina  of  the  vessels  in  the  villi  the  trophoderm  fails 
to  act  as  an  endothelium  for  the  intendllous  blood  spaces  around  the 
affected  villi.  Coagulation  of  the  blood  in  the  spaces  then  occurs  and 
fibrous  replacement  sets  in.  As  a  result  patches  of  fibrous  tissue  including 
villi  and  intervillous  blood  spaces  appear  in  any  full-term  placenta.  The 
term  generally  applied  to  these  fibrous  structures  is  placental  infarcts. 
They  are  regarded  merely  as  indications  of  senility  in  the  placenta,  and 
no  clinical  significance  is  attached  to  them  unless  they  become  so  exten- 
sive as  to  interfere  mechanically  with  the  function  of  the  organ. 

Small  areas  of  calcification  are  present  in  almost  all  full-term  placentee. 
They  stand  out  very  clearly  in  section  after  von  Kossa's  silver  nitrate 
method.  Fatty  degeneration  is  present  in  many  placentse,  usually  in 
the  maternal  side  of  the  organ.  ^Mucinous  degeneration  occurs  most 
frequently  in  the  larger  ^•illous  trunks  with  endarteritis  of  the  vessels. 
Fibrinous  degeneration  is  found  in  the  walls  of  the  bloodvessels  of  the 
villi  outside  of  the  areas  of  infarction  mentioned  above.  C^^stic  degenera- 
tion is  most  frequent  on  the  fetal  surface  of  the  placenta  just  beneath 
the  amnion. 

3.  Diseases  of  the  Placenta. — Placentitis,  or  inflammation  of  the  pla- 
centa, was  a  term  frequently  used  by  the  earlier  ■^Titers  but  was  applied 
by  them  to  infarcts  and  other  regressive  changes.  Acute  inflammation, 
which  is  very  rarely  present,  is  never  primary  in  the  fetal  portion  but  is 
due  to  an  extension  from  the  decidua  of  a  uterus  with  marked  endometritis. 

In  syphilis  of  the  placenta  three  macroscopic  features  may  be  noted. 
(1)  There  is  a  marked  increase  in  the  volume  of  the  organ,  due  in  large 
part  to  hA-pertrophy  of  the  villi.  The  ratio  between  the  size  of  the  placenta 
and  that  of  the  fetus  is  frequently  reduced  to  1:3  and  in  extreme  cases 
1:1.  (2)  The  color  instead  of  being  a  beefy  red  is  about  that  of  brain 
tissue.  (3)  The  organ  is  firm  or  hard  owing  to  the  great  amount  of  fibrous 
degeneration. 

Under  the  microscope  sections  of  a  syphilitic  placenta  show  a  diffuse 
productive  inflammation  of  the  villi,  the  stroma,  vessels  and  trophoderm 
all  taking  part  in  the  proliferation.  Early  cases  show  the  origin  of  the 
process  in  the  tips  of  the  villi.  The  connective-tissue  elements  of  the 
stroma  proliferate  and,  with  the  thickening  of  the  vessel  walls,  obliterate 
the  hmiina  of  the  vessels.  The  villi  then  appear  as  solid  strands  of 
connective  tissue.  Very  uneven  proliferation  of  the  syncytial  layer  occurs 
and  in  some  \\\li  these  growing  masses  break  through  into  the  stroma. 


110 


EMBRYOLOGY  AND  PHYSIOLOGY 


It  is  claimed  by  some  investigators  that  Langhans's  cells  also  proliferate 
in  luetic  placentae  instead  of  disappearing  as  in  normal  cases.  The 
intervillous  blood  spaces  are  obliterated  or  much  crowded  owing  to  the 
increase  in  size  of  the  villi.  The  several  forms  of  degeneration  seen  in 
normal  placenta  are  much  more  evident  in  s^'philitic  cases.  The  Spiro- 
cheta  pallida  has  been  found  principally  in  the  villi;  it  has  also  been 
demonstrated  in  the  miibilical  cord. 

Tuberculosis  of  the  placenta  is  rare.  It  may  be  found  in  the  presence 
of  a  maternal  miliary  tuberculosis  or  in  a  tuberculous  uterus.  It  is 
assumed  that  the  bacilli  lodge  in  the  ectoderm  layer  of  the  villi,  invade 
the  stroma  and  there  form  topical  tubercles  (Fig.  88). 


^-r^ 


.<r:> 


fe 


-^ 


Fig.  88. — Tuberculosis  of  the  placenta.  The  three  black  areas  are  tubercles  which  are 
stained  so  intenselj'-  that  in  this  low-power  photomicrograph  no  morphological  elements 
are  distinguishable. 


Neoplasms  of  the  Placenta. — New  groA\i:hs  of  the  placenta  are  rare. 
In  36  cases  collected  from  the  literature  the  tumors  were  all  of  the  con- 
nective-tissue t^'pe  and  grouped  as  follows:  fibromyxoma,  14;  fibroma,  10; 
angioma,  9;  sarcoma,  2;  hyperplasia  of  chorionic  villi,  1. 

The  Umbilical  Cord. — The  umbilical  cord  is  the  structure  connecting 
the  placenta  with  the  anterior  abdominal  wall  of  the  fetus.  It  is  of  a 
dull  pearh'  color  and  through  its  epithelial  covering  can  be  seen  the 
tortuous  vessels.  The  cord  is  covered  with  several  layers  of  epithelial 
cells  (ectoderm)  continuous  with  the  epidermis  of  the  fetal  abdominal 
wall.     It  contains  a  characteristic  mucinous  connective  tissue,  often 


THE  FETAL   VASCULAR  SYSTEM  111 

called  Wharton's  jelly — through  which  pass  the  umbilical  vein,  two 
umbilical  arteries,  the  remnants  of  the  allantois  and  of  the  umbilical 
vesicle,  although  the  two  last-named  structures  appear  usually  only  in 
cross-sections  near  the  fetal  end.  Because  of  the  torsion  of  the  contained 
vein  and  arteries — the  vessels  are  longer  than  the  cord  itself — the  cord 
has  a  twisted  appearance.  A  study  of  the  umbilical  cords  in  10,000 
consecutive  deliveries  at  the  Sloane  Hospital  gave  the  following  results: 
The  average  length  of  the  cord  was  59.1  cm.,  or  23.6  inches,  the  longest 
cord  being  140  cm.,  the  shortest  16  cm.  An  eccentric  insertion  was 
about  four  times  as  frequent  as  a  central,  the  implantation  in  the  10,000 
cases  being  between  the  centre  and  the  periphery  in  73.5  per  cent.,  central 
in  19  per  cent.,  marginal  in  6.5  per  cent,  and  velamentous  in  1  per  cent, 
of  the  cases.  The  spirals  starting  from  the  child  were:  to  the  left  in 
59  per  cent.;  to  the  right  in  23  per  cent;  to  the  left  and  right  in  16  per 
cent. ;  no  spirals  in  2  per  cent. 

Anomalies  of  the  Cord. — In  this  series  of  10,000  cords  the  following 
anomalies  were  observed:  Varicosities  in  11.5  per  cent.;  excess  of  Whar- 
ton's jelly  in  0.98  per  cent.;  knots  of  the  cord  in  0.98  per  cent.;  cysts  of 
the  cord  in  0.09  per  cent.;  tight  twists  of  the  cord  in  0.05  per  cent. 

Cord  About  the  Neck  of  the  Child. — The  cord  was  found  about  the  neck 
of  the  child  at  the  time  of  delivery  in  26.51  per  cent,  of  the  cases :  Around 
the  neck  once  in  22.63  per  cent.;  tightly  in  9  per  cent.  Around  the  neck 
twice  in  3.33  per  cent.;  tightly  in  1.5  per  cent.  Around  the  neck  thrice 
in  0.48  per  cent.;  tightly  in  0.24  per  cent.  Around  the  neck  four  times 
in  0.06  per  cent.  Around  the  neck  five  times  in  0.01  per  cent.  Around 
body  or  an  extremity  in  1.5  per  cent. 

THE   FETAL   VASCULAR   SYSTEM. 

A  discussion  of  the  complex  problem  of  the  origin  of  bloodvessels  is 
not  within  the  province  of  this  work.  Consequently  attention  will  be 
confined  to  the  course  of  the  main  vascular  trunks  in  the  embryo  with 
special  reference  to  the  relationship  between  these  and  the  vessels  in  the 
fetal  membranes. 

The  first  main  arterial  trunks  within  the  embryo  are  the  primitive 
aortse.  From  each  of  these  arises  a  vessel,  the  vitelline  artery,  which 
passes  out  through  the  splanchnopleure  to  ramify  in  the  mesodermal 
layer  of  the  yolk  sac.  Subsequently  the  two  aortse  fuse  to  form  the  single 
dorsal  aorta,  and  the  proximal  portions  of  the  vitelline  arteries  likewise 
coalesce  to  form  a  single  vessel  within  the  embryo.  The  aorta  is  connected 
with  the  heart  by  the  aortic  arches  which  pass  through  the  branchial 
arches  (Fig.  89).  Corresponding  to  the  vitelline  arteries  are  two  vitel- 
line veins  which  are  formed  by  convergence  of  vessels  on  the  yolk  sac 
and  which  enter  the  caudal  end  of  the  heart. 

There  is  thus  established  the  vitelline  or  yolk  sac  circulation  (Fig.  76). 
The  blood  is  forced  out  of  the  heart  into  the  aortic  arches,  thence  into  the 
dorsal  aorta  and  through  the  vitelline  arteries  into  the  vascular  network 
on  the  volk  sac.    From  this  network  the  blood  flows  into  vessels  converg- 


112 


EMBRYOLOGY  AND  PHYSIOLOGY 


ing  to  form  the  vitelline  veins  which  in  turn  open  into  the  heart.  Branches 
from  the  aorta  convey  blood  to  the  tissues  of  the  growing  body.  Small 
venous  channels  collect  the  blood  from  the  tissues  and  carry  it  to  a  pair 
of  longitudinal  veins  in  the  body,  the  cardinal  veins,  which  open  into 
the  heart  in  common  with  the  vitelline  veins  (Fig.  89). 

In  animals  such  as  birds  and  reptiles,  the  yolk  sacs  of  which  contain 
large  quantities  of  nutriment,  the  vitelline  circulation  is  of  prime  impor- 
tance in  conveying  the  nutriment  to  the  embryo.  In  mammals  including 
man,  although  the  yolk  sac  contains  but  little  yolk,  the  vitelline  circula- 
tion nevertheless  temporarily  undergoes  extensive  development. 

With  the  establishment  of  intimate  union  between  the  chorion  and 
uterine  wall  another  set  of  vessels  develops,  partly  in  the  embryo  and 


Dor -sal  aorta 

Primitive  jugular 
vein 


Cfwr ionic  villi 


Fig.  89. — Human  embr>-o  of  2.15  millimeters,  with  yolk  sac.     (After  His.) 

partly  in  the  membranes.  The  umbilical  fallantoic)  arteries  are  given 
off  from  the  aorta  near  its  caudal  end  and,  passing  along  the  urachus 
(see  page  97),  extend  through  the  belly  stalk  (later  the  umbilical  cord) 
to  the  chorion.  Here  they  branch  in  the  mesodermal  layer  and  send 
smaller  radicles  into  the  cores  of  the  chorionic  villi  (Fig.  77).  The 
blood  in  the  chorionic  villi  is  collected  in  small  veins  which  converge  to 
form  larger  channels  and  follow  the  course  of  the  arteries  back  to  the 
embryo.  In  the  mnbilical  cord  the  two  umbilical  veins  fuse  to  form  a 
single  vessel.  The  vessels  seen  in  the  umbilical  cord  are  therefore  the 
two  umbilical  arteries  and  single  umbilical  vein  (Fig.  90). 

The  development  of  the  intra-embryonic  portion  of  the  umlnlical  veins 
is  much  more  complex.  At  first  they  are  paired  structures,  one  on  each 
side  in  the  ventrolateral  part  of  tlie  l)ody  wall,  and  open  into  the  heart 


THE  FETAL   VASCULAR  SYSTEM 


113 


in  common  with  the  cardinal  and  vitelhne  veins.  Later  the  left  umbilical 
vein  establishes  a  more  direct  course  through  the  liver,  the  portion  within 
the  liver  being  known  as  the  ductus  venosus  (Fig.  90).  The  bulk  of 
the  blood  from  the  placenta  then  follows  this  course  and  the  right  umbilical 


Vena  cava 
superior 


Ductus 
venosus 


Hepatic 
vein 


Ductus 
arteriosus 


Umbil. — I 
artery 


Fig.  90. — The  fetal  circulation.      (Kollmann's  Atlas.) 

vein  atrophies,  loses  its  direct  connection  with  the  heart  and  becomes 
merely  a  small  vessel  opening  into  the  left  vein  at  the  umbilicus. 

The  umbilical  arteries  and  veins  constitute  the  channels  for  blood 
circulating  between  the  embryo  and  the  placenta.    This  blood  conveys 


114 


EMBRYOLOGY  AND  PHYSIOLOGY 


nourishment  from  the  placenta  to  the  embryo  and  waste  products  in 
the  reverse  direction.  In  the  placenta  the  exchange  of  food  and  waste 
between  fetus  and  mother  takes  place. 

Changes  in  the  Circulation  at  Birth. — During  fetal  life  the  course  of 
the  blood  is  adapted  to  the  placental  circulation.  The  pure  blood  from 
the  placenta  passes  through  the  umbilical  vein  to  the  liver.  Here  a  part 
is  distributed  to  the  liver  itself  while  a  part  passes  on  to  the  heart  via 
the  ductus  venosus  and  inferior  vena  cava  (Fig.  91).  In  the  vena  cava 
this  pure  blood  mingles  with  impure  blood  from  the  cava  itself  and  the 
portal  vein.  The  mixed  blood  then  flows  into  the  right  auricle  whence  it  is 
directed  bv  the  Eustachian  valve  throus'h  the  foramen  ovale  into  the  left 


Sup.  vena  cava 
Lungs 

Right  atrium 

Right  ventricle 

Inf.  vena  cava 

Liver 

Ductus  venosus 

Placenta 

Inf.  vena  cava 

L  nibilical  vein 


Umbilical 
artery 


Ant.  part  of 
body 


Carotid  and 
subclavian 
arteries 

Ductus 
arteriosus 

Pulmonary 

artery 
Left  ventricle 


Hepatic  artery 


Portal  vein 


Intestinal 
circulation 


Post,  part  of 
body 


Fig.  91. — Diagram  illustrating  the  fetal  circulation.  The  shading  represents  the  relative 
impurity  of  the  blood  in  difTcrent  regions,  the  darkest  shading  representing  the  most  impure 
blood.      (Modified  from  KoUmann.) 


auricle.  From  this  it  passes  into  the  left  ventricle  and  is  forced  out  into  the 
aorta.  A  part  of  the  blood  then  flows  on  through  the  aorta  and  a  part  is 
carried  to  the  head  and  neck  and  upper  extremities  by  the  carotid  and 
subclavian  arteries.  The  latter  part,  becoming  impure,  is  carried  to  the 
right  auricle  by  the  jugular  and  subclavian  veins  and  superior  vena  cava ; 
it  then  passes  into  the  right  ventricle  and  is  forced  out  into  the  pulmo- 
nary artery.  But  since  the  lungs  are  non-functional,  this  ])]()()d  passes 
through  the  ductus  arteriosus  (Fig.  90)  to  join  the  stream  in  the  aorta. 

The  blood  from  the  left  ventricle  going  to  the  more  cephalic  portion 
of  the  embryo  is  but  slightly  impure,  for  the  very  impure  blood  from  the 
ductus  arteriosus  joins  the  aortic  stream  distal  to  the  subclavian  and 
carotid  arteries.    This  probably  accounts  for  the  fact  that  the  head  and 


THE  FETAL   VASCULAR  SYSTEM 


115 


upper  extremities  of  the  embryo  are  better  developed  than  the  lower 
extremities.  It  may  be  noted,  too,  that  the  liver  receives  the  purest 
blood,  which  fact  is  correlated  with  the  enormous  size  of  this  organ 
in  the  fetus. 

The  impure  blood  of  the  dorsal  aorta  is  in  part  distributed  to  the  viscera, 
body  wall  and  lower  extremities  and  in  part  carried  to  the  placenta  by 
the  umbilical  (hypogastric)  arteries.  The  blood  distributed  in  the  embryo 
is  carried  back  to  the  heart  as  impure  blood  which  mingles  with  the  pure 
umbilical  current  at  the  liver.  The  blood  taken  to  the  placenta  is  there 
purified  and  returns  to  the  embryo  via  the  umbilical  vein. 


Sup.  vena  cava  ' 

Lungs- 

Pulmonary 
veins 

Right  atrium - 
Right  ventricle  • 
Inf.  vena  cava ' 

Hepatic  vein  ■ 


Liver  •" 


Inf.  vena  cava 


Post,  part  of 
body 


T^-V 


Fig.  92. — Diagram  illustrating  the  circulation  in  the  adult.  Compare  with  Fig.  91. 
The  shading  represents  the  relative  impurity  of  the  blood,  the  white  being  the  purest  blood. 
(Bailey  and  MUler.) 

With  the  birth  of  the  child  and  the  detachment  of  the  placenta,  the 
function  of  five  structures,  which  up  to  this  time  have  been  important, 
is  no  longer  needed.    These  structures  are: 
1.  The  umbilical  vein. 
The  ductus  venosus. 
The  foramen  ovale. 
The  ductus  arteriosus. 
^.  The  hypogastric  arteries. 
With  the  detachment  of  the  placenta  and  expansion  of  the  lungs  all 
of  these  structures  begin  to  be  obliterated. 

At  the  end  of  the  first  week  the  umbilical  vein,  the  ductus  venosus  and 


116  EMBRYOLOGY  AND  PHYSIOLOGY 

all  but  the  proximal  portions  of  the  hypogastric  arteries  have  normally 
become  impervious  fibrous  cords.  The  proximal  portion  of  the  last- 
named  vessels  persist  as  the  superior  vesical  arteries.  The  obliterated 
imibilical  vein  becomes  the  round  ligament  of  the  liver. 

With  the  assumption  by  the  lungs  of  the  normal  function  of  respira- 
tion, the  communication  between  the  two  auricles  and  that  between 
the  pulmonary  artery  and  the  aorta  should  cease.  The  foramen  ovale 
normally  closes  soon  after  birth.  If  this  opening  persists,  allowing  a 
mixture  of  the  blood  of  the  auricles,  a  condition  of  cyanosis  of  the  body 
is  produced  called  in  the  infant  cyanosis  neonatorum,  and  later  morbus 
cendeus. 

By  the  end  of  the  third  week  the  ductus  arteriosus  has  normally 
become  an  impervious  cord  called  the  ligamentum  arteriosum. 

EXTERNAL  FORM  OF  THE  BODY. 

It  has  been  stated  in  the  foregoing  account  of  early  development 
that  the  rudiment  of  the  mammalian  embryonic  body  is  a  disk-shaped 
structure  composed  of  ectoderm,  mesoderm  and  entoderm  (compare 
Figs.  60  and  61).  The  principles  underlying  the  development  of  the 
typical  cylindrical  or  tubular  form  are  the  ventral  flexion  of  the  margin 
of  the  disk,  a  concomitant  elongation  in  the  direction  of  the  primitive 
streak  (which  indicates  the  caudal  end  of  the  body),  and  of  the  primitive 
axis  and  then  a  further  constriction  from  the  underlying  yolk  sac.  This 
last  process  is  one  of  unequal  growi;h  rather  than  of  actual  constriction 
in  that  the  developing  embryonic  body  grows  more  rapidly  than  its 
attachment  to  the  yolk  sac.  In  a  general  way  the  application  of  the 
above  principles  results  in  a  tube  within  a  tube,  the  outer  comprising 
the  ectoderm  and  the  inner  the  entoderm,  with  mesoderm  between  the 
two.  In  the  meantime  the  mesoderm  splits  into  two  layers — an  outer  or 
parietal  which  is  apposed  to  ectoderm  and  an  inner  or  visceral  which  is 
apposed  to  entoderm — the  cleft  between  representing  the  body  cavity 
or  celom.  Ks  the  result  of  the  flexion,  therefore,  the  ectoderm  and  parietal 
mesoderm  (somatopleure)  constitute  the  body  wall  while  the  entoderm 
and  visceral  mesoderm  (splanchnopleure)  constitute  the  wall  of  the  gut. 
The  body  cavity  is  the  space  between  the  two  walls. 

The  contour  of  the  body  is  affected  during  development  by  the  appear- 
ance of  certain  additional  structures.  First  a  groove  with  ele\ated  borders 
appears  on  the  dorsal  side.  This  is  the  rudiment  of  the  nervous  system 
—the  neural  groove  (Fig.  75).  The  cephalic  portion  of  the  groove 
expands  more  rapidly  than  the  remaining  portion,  thus  indicating  the 
differentiation  into  brain  and  spinal  cord  (Fig.  93).  Both  brain  and 
spinal  cord  subsequently  become  enclosed  within  the  dorsal  body  wall, 
the  brain,  however,  leaving  a  permanent  effect  upon  the  contour  of  the 
head  region. 

The  further  changes  in  the  contour  of  the  cylindrical  liody  are  effected 
mainly  through  the  differentiation  of  the  head,  neck  and  body  regions, 
along  with  certain  flexions,  and  through  the  development  of  the  extremi- 
ties.   The  first  obvious  change  is  an  increase  in  size  of  the  head  end  of  the 


EXTERNAL  FORM  OF  THE  BODY 


117 


embryo,  concomitant  with  the  above-mentioned  expansion  of  the  neural 
tube  (Fig.  93).  The  extreme  end  of  the  head  region  is  also  bent  at  an 
approximate  right  angle  to  the  long  axis  of  the  body.  This  occurs  in  the 
midbrain  region  and  is  called  the  cephalic  flexure  which  remains  as  a 
permanent  feature  of  the  brain.  A  slight  concavity  in  the  dorsum  of 
the  embryo,  which  is  but  a  temporary  feature,  is  the  dorsal  flexure. 
The  depression  on  the  ventral  side  of  the  head  region,  produced  by  the 
cephalic  flexure,  is  the  rudiment  of  the  oral  and  nasal  cavities  and  is 
known  as  the  oral  fossa.  A  slight  protrusion  on  the  ventral  side  of  the 
body  is  caused  by  the  rapidly  developing  heart. 


Midbrain 


Hindbrain 


Forebrain 


Oral  fossa 


Amnion 


Yolk  sac 


Neural'oanal 


Belly  stalk 


Fig.  93. — Human  embryo  of  2.4  mm.   (14  primitive  segments).      (Kollmann's  Atlas.) 

In  further  development  the  body  becomes  more  robust  (Fig.  76). 
The  dorsal  flexure  disappears,  and  the  dorsum  becomes  convex,  due  to 
the  appearance  of  a  cervical  flexure,  which  indicates  the  future  neck 
region,  and  a  sacral  flexure  indicating  the  rump.  The  heart  protrusion 
increases  temporarily.  The  oral  fossa  increases  in  depth  through  the 
development  of  certain  structures  along  the  sides  of  the  neck  region. 
These  are  apparent  on  the  surface  as  alternate  elevations  and  depressions 
extending  dorsoventrally,  the  elevations  comprising  the  branchial  at'ches, 
of  which  four  are  formed  in  the  human  embryo,  and  the  depressions  com- 
prising the  branchial  grooves,   of  which  a  like  number  develops.     The 


lis 


EMBRYOLOGY  AXD  PHYSIOLOGY 


first  arch  ditl'erentiates  into  two  parts:  a  lower  or  mandibular  process 
which  grows  ventral  to  the  oral  fossa  and  forms  the  rudiment  of  the  lower 
jaw,  and  an  upper  or  maxillary  which  grows  lateral  to  the  oral  fossa  and 
represents  the  begiiniing  of  the  upper  jaw.  The  angle  between  the  two 
processes  represents  the  angle  of  the  mouth.  The  branchial  arches  and 
grooves  are  homologues  of  the  gill  bars  and  slits  in  the  lowest  vertebrates, 
the  fishes. 

The  flexures  mentioned  above  increase  imtil  the  embryo  reaches  a 
length  of  from  7  to  8  millimeters  (an  age  of  about  four  weeks), 
resulting  in  a  Ixxly  form  whose  dorsal  line  is  almost  a  circle  (Fig.  94). 

Cervical 
depression 


Branchial  arch  I 


Dorsal  flexure 


Lower  linih 
bud 


Primitive 
segments 


Upper  limb  bud     Liver  >a   :;il  Hexure 

Fig.  94. — Human  embryo  with  tweiity-seveu  primitive  segments  (7  mm.,  twenty-six  days). 

(Mall.) 

A  new  convex  dorsal  flexure  in  the  thoracic  region  adds  to  the  general 
convexity  of  the  dorsum  of  the  body,  while  a  slight  concavity — the 
cervical  depression — indicates  the  back  of  the  neck.  The  heart  continues 
to  bulge  on  the  generally  concave  ventral  side  of  the  body  and  the  rapidly 
developing  liver  produces  a  second  protrusion.  Two  buds,  or  rather 
sharply  circumscribed  elevations,  appear  on  each  side  of  the  body.  One 
of  these,  opposite  the  new  dorsal  flexure,  is  the  rudiment  of  the  upper 
limb;  the  other,  opposite  the  sacral  flexure  is  the  beginning  of  the  lower 
limb  (Fig.  94).  The  branchial  grooves  and  arches  become  temporarily 
more  prominent.. 


EXTERNAL  FORM  OF   THE  BODY  119 

During  the  fifth  week  the  embrj'o  becomes  straighter,  principally 
through  reduction  of  the  cervical  and  dorsal  flexures  (Fig.  95,  w)-  The 
sacral  flexure  is  slightly  reduced  while  the  strong  cephalic  persists.  The 
protrusions  on  the  ventral  side  of  the  body,  caused  by  the  heart  and 
liver,  merge  into  a  general  rotundity.  The  fourth  and  third  branchial 
arches  disappear  in  order,  being  incorporated  in  the  neck  which  is  gradually 
appearing  as  a  more  slender  portion  of  the  embryo.  The  second  and  first 
arches  remain  as  prominent  features  for  a  time.  The  eye  appears  as  a 
prominent  feature  at  the  angle  between  the  base  of  the  first  arch  and  the 
forebrain  region.  Each  limb  bud  begins  to  show  a  differentiation  into 
a  flattened  distal  portion,  the  rudiment  of  the  hand  (or  foot),  and  a  cylin- 
drical proximal  portion,  the  rudiment  of  the  arm  and  forearm  (or  thigh 
and  leg). 

The  further  changes  in  the  general  contour  of  the  body  comprise 
principally  the  further  reduction  of  .the  flexures  (except  the  cephalic), 
with  the  result  that  the  embryo  as  a  whole  lies  in  a  nearly  straight  line 
(Fig.  96).  The  rudiments  of  the  limbs,  at  first  parallel  to  the  long  axis 
of  the  body,  turn  at  right  angles  to  the  long  axis.  Subsequently  they 
return  to  the  original  position.  The  conch  of  the  ear  develops  from 
external  portions  of  the  first  and  second  arches,  the  external  auditory 
meatus  being  the  dorsal  end  of  the  first  groove.  The  rest  of  the  second 
arch  becomes  incorporated  in  the  neck,  while  the  first  arch  is  in  the  main 
involved  in  the  development  of  the  face. 

As  previously  stated,  the  branchial  arches  and  grooves  for  the  most 
part  are  incorporated  in  the  neck.  The  first  arch,  however,  is  a  most 
important  factor  in  the  development  of  the  face.  Of  the  two  processes 
into  which  it  is  differentiated,  the  mandibular  increases  rapidly  in  size 
and  grows  ventrally  until  it  meets  and  fuses  with  its  fellow  of  the  opposite 
side  in  the  midventral  line,  thus  producing  the  lower  jaw  and  chin  (Figs. 
97  and  98).  The  maxillary  process  meets  and  fuses  with  a  i^rocess 
(the  nasofrontal)  which  grows  downward  from  the  forebrain  region 
(Figs.  97  and  98).  The  line  of  fusion  is  indicated  externally  by  the 
naso-optic  furrow.  The  nasofrontal  process  secondarily  gives  rise  to  a 
middle  and  a  lateral  nasal  process  on  each  side,  and  a  depression  between 
these  two  represents  the  nasal  fossa.  The  maxillary  process  then  fuses 
with  the  lateral  and  also  possibly  with  the  middle  nasal  process  on  each 
side  and  gives  rise  to  the  upper  lip  (Fig.  97). 

Age  and  Length  of  Embryos. — The  age  of  the  embryo  must  be  dated 
from  the  time  of  fertilization;  but  owing  to  the  fact  that  this  time  is 
not  definitely  known  in  the  human  being  the  exact  age  cannot  be  deter- 
mined. It  is  convenient  for  practical  purposes,  however,  to  have  some 
means  of  approximating  the  age.  This  is  usually  accomplished  by  the 
following  rule :  According  to  Hasse,  the  length  of  the  fetus  in  centimeters 
is  approximately  the  square  of  the  age  in  lunar  months  up  to,  and  includ- 
ing, five  lunar  months.  After  that  the  length  of  the  fetus  in  centimeters 
may  be  calculated  by  multiplying  the  number  of  the  lunar  month  by  5. 
Thus :  At  1  lunar  month  the  length  is  1  cm. ;  at  2  lunar  months  the  length 
is  4  cm. ;  at  3  lunar  months  the  length  is  9  cm. ;  at  4  lunar  months  the  length 
is  16  cm.;  at  5  lunar  months  the  length  is  25  cm.;  at  6  lunar  months  the 


120 


EMBRYOLOGY  AND  PHYSIOLOGY 


Fig.  95. 


-p.  the  embryos  of  His's  Xormentafel,  from  the  Xormentafel  of  Keibel  and  Elze. 
X  5.     His's  numbers  are  given  in  parentheses. 


EXTERNAL  FORM  OF   THE  BODY 


121 


Fig.  96. — q-z,  the  embryos  of  His's  Normentafel.      X  2.5.     His's  numbers  are  given  in 
parentheses.      (From  the  Normentafel  of  Keibel  and  Elze.) 

o    (H)  embryo  of  11.0  mm. 


a    {  1)   embryo  of     2.1    mn 

b     (  S) 

2.2 

c     (  3) 

2.15      ' 

d    (  4) 

2.2 

e     (  5) 

2.6 

f     (  6) 

4.2 

0    (  7) 

4.0 

h    (  8) 

5.5 

i     (  9) 

7.5 

k    (10) 

10.0 

I     (11) 

9.1 

m  (12) 

9.1 

n    (IS) 

10.5 

P   (15) 

11.5      ' 

q     (16) 

12.5      ' 

r     (17) 

13.7      " 

s     (18) 

13.8      " 

t     (I'J) 

13.6      " 

u    (20) 

14.5      " 

V     (21) 

15.5      " 

w  (22) 

16.0      " 

X    (23) 

17.5      " 

y    (2h) 

18.5      " 

z    (25) 

23.0      ' 

122 


EMBRYOLOGY   AXD   PHYSIOLOGY 


length  is  30  cm.;  at  7  lunar  months  the  length  is  'Ao  cm.;  at  S  lunar  months 
the  length  is  40  cm.;  at  9  lunar  months  the  length  is  45  cm.;  at  10  lunar 
months  (term)  the  length  is  50  cm. 


Midbrain 


Cerebral  hemisphere 

Lat.  nasal  process 

Xasal  pit 

Med.  nasal  process 

Angle  of  mouth 


Eye 

Naso-optic  furrow 

Maxillary  process 
Mandibular  process 

Branchial  grooves 
Branchial  arch  II 


Fig.   97. — Ventral  view  of  head  of  11.3  mm.  human  embryo.      (Rabl.) 


Branchial  groove  I 
(external  ear) 


Maxillary  process 
Med.  nasal  process 


Fig.  98. — Ventral  view  of  head  of  human  embryo  of  eight  weeks.      (His.) 

A  description  of  the  development  of  the  various  tissues,  organs,  and 
systems,  which,  to  be  complete,  would  necessarily  be  long,  is  scarcely 
within  the  scope  of  a  book  of  this  character.  For  this  the  student  is 
therefore  referred  to  the  various  text-books  of  embr^'olog^^ 


PART  II. 

PHYSIOLOGICAL  PREGNANCY  AND  ITS 
MANAGEMENT. 


CHAPTER  HI. 
CHANGES  PRODUCED  IX  THE  :NLATERXAL  ORGANISM. 

Although  the  existence  of  pregnancy  naturally  produces  the  most 
marked  changes  in  the  uterus  and  the  other  distinctively  generative 
organs,  and  these  changes  will  be  first  considered,  there  is  hardly  an  organ 
or  tissue  in  the  body  which  does  not  respond  in  greater  or  less  degree  to 
the  increased  stimulation  and  increased  demand  caused  by  impregnation. 

Changes  in  the  Uterus. — Under  the  influence  of  pregnancy  the  uterus 
changes  from  the  small,  firm  organ  measuring  about  7.5  cm.  (3  inches)  in 
length,  5  cm.  (2  inches)  in  breadth  at  fundus,  and  2.5  cm.  (1  inch)  in 
thickness,  with  a  capacity  of  about  1  cubic  inch  and  weighing  about  40 
to  50  gm.  (1|  ounces),  to  the  large,  soft,  muscular  sac  found  at  term  meas- 
uring about  30  cm.  (1  foot)  in  length,  weighing  about  1  kilogram  (2 
pounds)  and  having  a  capacity  of  about  400  cubic  inches,  capable  of 
containing  a  fetus  weighing  from  7  to  10  pounds  together  with  a  quart 
or  more  of  liquor  amnii.  Not  only  is  the  uterus  increased  in  size  but 
there  are  changes  in  its  shape,  structure  and  position. 

Changes  in  Shape. — During  the  first  month  the  uterus  maintains  its  flat- 
tened pyriform  shape,  but  during  the  next  few  months  the  lower  portion 
of  the  uterine  body  expands  more  rapidly  than  does  the  upper  portion 
and  the  uterine  body  assumes  nearly  the  shape  of  a  sphere  resting  on 
the  cylindrical  cervix.  The  lower  uterine  segment  becomes  more  com- 
pressible and  on  account  of  this  and  the  increased  weight  of  the  uterine 
body  the  normal  anteflexion  is  increased  during  the  early  months.  Later 
this' gradually  disappears.  After  the  fourth  or  fifth  month  the  uterus 
resumes  its  pyriform  shape.  Owing  to  the  pressure  of  the  abdominal 
walls  in  front  and  the  spinal  column  behind  the  transverse  diameter 
of  the  uterus,  after  the  middle  of  pregnancy,  is,  save  during  the  period 
of  contraction,  markedly  in  excess  of  the  anteroposterior  diameter. 
With  each  uterine  contraction  the  anteroposterior  diameter  increases 
(see  p.  212).  _         . 

Changes  in  Structure.— The  first  structural  changes  visible  m  the 
uterus  as  a  result  of  pregnancv  appear  in  the  mucous  membrane  which 

(123) 


124 


CHANGES  PRODUCED  IN  MATERNAL  ORGANISM 


becoming  more  vascular,  thicker  and  softer,  results  in  the  formation  of 
the  decidua  already  described  (see  p.  105). 

The  increase  in  the  size  of  the  uterus  during  the  first  half  of  preg- 
nancy is  chieHy  due  to  the  h\  pertrophy  of  its  nuiscular  fibers,  and  an 
increase  in  all  the  constituent  elements  of  the  muscular  wall,  the  con- 
nective tissue,  blood^'essels,  hmphatics  and  nerves.  The  muscular 
fibers  become  immensely  hypertrophied,  some  of  them  in  the  pregnant 
uterus  measuring  ten  times  as  long  and  five  times  as  broad  as  in  the  non- 
pregnant organ.  These  changes  will  be  seen  by  compjaring  Figs.  99 
and  100.  It  is  during  this  period  of  Inpertroph}'  that  the  arrangement 
of  the  muscular  fibers  in  three  lavers — the  external,  middle  and  internal 


FlG.  99. — Normal,  non-pregnant  uterine  muscle.      X  200. 


can  be  most  easily  differentiated.  The  connective  tissue  is  markedly 
increased  at  this  time  and  sends  in  bundles  between  the  muscular  fibers. 
The  arteries  increase  greatly  in  length,  caliber  and  tortuosity.  At  the 
site  of  placental  attachment  they  empty  directly  into  the  dilated  uterine 
veins.  The  veins  of  the  pregnant  uterus  dilate,  especially  near  the 
placental  site,  into  large  uterine  sinuses  whose  walls  are  intimately  blended 
with  the  connective  tissue  and  surrounded  by  the  muscle  bundles  of  the 
muscular  wall.  By  the  relaxation  and  contraction  of  these  muscle- 
fibers  the  uterine  sinuses  are  opened  and  closed. 

The  lymphatics  of  the  pregnant  uterus  share  in  the  general  hypertrophy 
of  the  uterine  structures.  They  become  markedly  developed  just  be- 
neath the  mucous  membrane  and  beneath  the  peritoneum,  especially  at 


CHANGES  IN   THE   UTERUS 


125 


the  sides  and  about  the  fundus  of  the  uterus.  These  plexuses  of  lym- 
phatics, lining,  covering  and  penetrating  the  muscular  wall  of  the 
uterus  readily  explain  the  easy  passage  of  infection  from  the  uterine 
cavity  to  the  general  system. 

The  nerves  of  the  pregnant  uterus  increase  in  size  especially  in  the 
thickness  of  the  neurilemma.  The  ganglia  about  the  uterus  also  undergo 
hypertrophy,  especially  the  cervical  ganglion.  The  peritoneal  covering 
of  the  uterus  keeps  pace  in  growth  with  the  constantly  enlarging  uterus. 
It  remains  firmly  attached  to  the  upper  part  of  the  uterus  but  is  easily 
separated  from  the  low^er  uterine  segment. 


Fig.  100. — Muscle  of  uterus  at  term.      X  200. 

Changes  in  the  Cervix. — During  the  first  three  months  the  cervix  shares 
in  the  general  hypertrophy  of  the  uterus,  and  reaches  a  length  of  about 
5  cm.  (2  inches).  After  this  period  relatively  little  change  occurs,  until 
the  last  month  of  pregnancy  when  the  cervix  apparently  shortens.  As 
a  result  of  the  hyperemia  accompanying  the  development  of  the  cervix, 
its  tissue  softens,  the  cervix  as  a  whole  assumes  a  violet  hue,  and  its 
mucous  follicles  secrete  a  viscid  mucus,  which  fills  the  cervical  canal  and 
is  called  the  mucous  plug. 

The  softening  of  the  cervix,  which  begins  early  in  pregnancy  about  the 
external  os,  gradually  increases  until  it  involves  the  whole  cervix. 

The  cavity  of  the  cervix  dilates  as  pregnancy  advances  and  during 
the  last  month  even  in  primigravidse  admits  the  finger  tip.  This  dila- 
tation in  primigravidse  begins  first  at  the  internal  os  and  extends  down- 


126  CHAXGES  PRODUCED  IX   MATERXAL  ORGAXISM 

ward  giving  the  canal  a  funnel-shape  with  apex  at  the  external  os.  In 
miiltigravidse  this  dilatation  begins  earlier  and  is  more  pronounced  than 
in  primigravidff.  ^Moreover,  in  multigravidse  the  dilatation  usually  begins 
at  the  external  os  first. 

During  the  latter  half  of  pregnancy  on  account  of  the  softening  of  the 
cervix  and  the  softening  and  thickening  of  the  vaginal  walls  about  it, 
the  cervix  gives  an  apparent  feel  of  being  shortened.  During  the  last 
two  weeks  there  occurs  an  actual  shortening  of  the  cer^•ix  as  a  result 
of  the  contraction  of  the  longitudinal  muscle  fibers  of  the  uterus  and 
an  appropriation  of  the  upper  part  of  the  cervix  by  the  lower  uterine 
segment. 

Position  of  the  Uterus. — During  the  first  two  months  of  pregnancy  the 
uterus  from  its  increased  weight  sinks  a  little  in  the  pelvis.  During  the 
first  three  months  the  enlargement  of  the  organ  is  chiefly  in  the  antero- 
posterior and  lateral  diameters  and  the  fundus  does  not  usually  rise 
above  the  pelvic  brim.  In  the  fourth  month  the  fundus  rises  above  the 
s\'mphysis  pubis.  At  five  months  the  fundus  lies  midway  between  the 
symphysis  and  the  umbilicus;  at  six  months  at  the  level  of  the  um- 
bilicus; at  seven  months  at  one-third  the  distance  between  the  umbilicus 
and  ensiform  cartilage;  at  eight  months  at  two-thirds  the  distance;  and 
at  eight  and  one-half  months  approximately  at  the  ensiform  cartilage. 
In  speaking  of  months,  calendar  months  are  intended.  During  the  last 
two  weeks  of  pregnancy  the  uterus  with  its  contained  fetus  settles  in 
the  pelvis,  sometimes  called  "lightening,"  allowing  more  normal  use 
of  the  thoracic  organs  and  bringing  the  fundus  uteri  to  about  the  level 
occupied  at  the  end  of  eight  months.  On  account  of  the  presence  of 
the  sigmoid  flexure  and  rectum  on  the  left  side,  the  centre  of  the  preg- 
nant uterus  usually  lies  a  little  to  the  right  of  the  median  line  of  the 
abdomen  and  there  is  usually  a  slight  rotation  of  the  uterus  on  its  longi- 
tudinal axis  so  that  its  anterior  surface  looks  a  little  to  the  right.  The 
abo\e  given  positions  of  the  uterus  are  only  approximate  and,  of  course, 
depend  largely  on  the  position  of  the  woman  and  the  laxit\'  of  the  abdom- 
inal walls.    They  apply  chiefly  with  the  woman  in  the  dorsal  position. 

With  the  growth  of  the  jjregnant  uterus  the  round  ligaments  become 
hypertrophied  and  can  often  be  felt  through  the  abdominal  wall  as 
rounded  cords  extending  from  the  inguinal  canals  to  the  uterus.  As 
the  uterus  rises  in  the  abdomen  the  uterine  ends  of  the  Fallopian  tubes 
become  elevated,  so  that  the  course  of  the  tubes  from  uterus  to  o\aries 
is  more  nearly  vertical.  The  F'allopian  tubes  in  a  lesser  degree  present 
the  congestion  and  hy|>ertr()ph>'  seen  in  the  uterus. 

Along  with  this  upward  gro^^■th  of  the  uterus  the  ovaries  gradually 
rise  out  of  the  pehis. 

Menstruation. — The  function  of  menstruation  is  usually  absent  during 
pregnancy.  Exceptionally,  occasional  menstruation  occurs  during  the 
first  three  months. 

Changes  in  the  Vagina. — Owing  to  the  increased  vascularity  of  the 
vagina  there  occurs  a  thickening  and  softening  of  the  mucous  membrane, 
an  increase  in  its  secretion,  a  deepening  of  its  color  (the  vagina  in  the 


CHANGES  IN   THE  MAMMARY  GLANDS 


127 


later  months  assuming  a  violet  hue),  and  a  general  growth  of  the  vaginal 
walls.  The  external  genitals  share  to  a  lesser  degree  the  increase  in 
vascularity,  secretion  and  color  noted  in  the  vagina.  With  the  advance 
of  the  pregnane}'  there  occurs  a  gradual  downward  displacement  of  the 
pelvic  floor. 

Changes  in  the  Mammary  Glands.— Next  to  the  pelvic  organs  the 
mammary  glands  present  the  most  marked  evidences  of  growth  and 
development  incident  to  pregnancy.  As  early  as  the  latter  part  of  the 
second  month  they  begin  to  enlarge  and  to  feel  fuller  and  firmer  to  the 
patient. 

Beginning  near  the  periphery  and  extending  toward  the  nipple  can  be 
felt  the  knotted  cords  produced  by  the  developing  lobules  and  ducts. 


Fig.   101. — Primary  areola  in  a  blonde. 


The  breasts  themselves  stand  out  more  prominently  from  the  chest  and 
over  them  course  veins  whose  bluish  markings  become  more  distinct  as 
pregnancy  advances. 

The  pigmented  base  upon  which  the  nipple  rests  becomes  gradually 
darker  from  increase  in  pigment  and  is  called  the  xjrimary  areola.  The 
color  varies  with  the  complexion  of  the  individual  (see  Figs.  101-104). 
In  the  light  blonde  there  is  but  little  pigment,  but  even  in  her  the  areola 
assumes  a  more  congested  appearance.  In  the  brunette  the  areola 
becomes  dark  brown,  or  in  some  cases  even  almost  black.  Scattered 
over  the  primary  areola,  which  is  often  elevated  above  the  level  of  the 
surrounding  breast  and  varying  from  1  to  20  in  number,  are  little  papil- 
lary projections,  often  about  the  size  of  buckshot,  called  the  "tubercles 


128  CHANGES  PRODUCED  IX  MATERNAL  ORGANISM 


Fig.   102. — Primary  areola  in  a  brunette,  showing  tubercles  of  Montgomery  and  engorged 

veins. 


Fig.   10-3. — Primary  and  secondary  areola  in  a  ncgress. 


CHANGES  IN  THE  MAMMARY  GLANDS 


129 


of  Montgomery."     They  are  really  sebaceous  glands  whose  function 
seems  to  be  the  lubrication  of  the  nipple  and  areola.    Under  the  influence 


Fig.  104. — Primary  areola  in  a  brunette,  showing  tubercles  of  Montgomery. 

of  pregnancy  the  circular  muscle  underlying  the  areola  becomes  more 
sensitive,  and  through  the  stimulation  of  friction,  cold  or  sometimes 


Fig.  105. — Primary  areola,  showing  wrinkling  from  contraction  of  the  circular  muscle  due 

to  stimulation  of  nipple. 


even  emotion,  it  readily  contracts,  throwing  the  areola  into  wrinkles, 
converging  toward  the  nipple  (see  Fig.  105),  and  making  the  latter  more 
9 


130  CHAXGES  PRODUCED  IX  MATERXAL  ORGAXISM 


Fig.   106. — Primarj-  and  secondarj'  areolae. 


Fig.   107. — Showing  primary  and  secondarj-  areolae  and  stria  of  the  breasts. 


GENERAL  CHANGES  DURING  PREGNANCY  131 

prominent.  This  is  sometimes  spoken  of  as  "erection  of  the  nipple," 
although  the  nipple  is  not  composed  of  erectile  tissue. 

By  about  the  end  of  the  third  month  of  pregnancy  there  can  often  be 
expressed  from  the  nipple  a  few  drops  of  fluid  either  clear  or  cloudy 
called  colostrum,  the  earliest  representative  of  the  milk.  During  the 
later  months  the  escape  of  some  of  this  fluid  from  the  nipple  often  forms 
crusts  upon  it  unless  care  is  taken  to  keep  the  nipple  clean. 

Secondary  Areola. — From  about  the  middle  of  pregnancy  there  appears 
immediately  outside  the  primary  areola  a  zone  characterized  by  num- 
erous whitish  spots  upon  a  darker  pigmented  background,  each  light  spot 
representing  the  opening  of  a  sebaceous  follicle  (see  Fig.  106).  This 
spotted  zone  is  called  the  "secondary  areola"  and  is  usually  more  marked 
in  the  brunette  than  in  the  blonde. 

During  the  later  months,  as  a  result  of  the  tension  of  the  skin  covering 
the  enlarging  breasts,  brownish  or  purplish  strise  often  appear  (see  Fig.  107), 
similar  to  those  which  will  be  described  later  as  occurring  on  the  abdomen 
and  like  them  they  tend  to  remain  as  permanent  silvery  markings. 

GENERAL   CHANGES    DURING   PREGNANCY. 

Digestion  and  Nutrition. — When  it  is  considered  that  during  pregnancy 
the  woman  eats,  breathes,  secretes  and  excretes  for  two,  it  is  easily 
understood  that  the  thoracic  and  abdominal  viscera  are  taxed  to  an 
extent  far  beyond  the  normal.  While  some  women  go  through  pregnancy 
with  no  disturbances  of  digestion  and  never  feel  as  well  as  in  that  condi- 
tion, this  is  the  exception,  and  disturbances  of  digestion  with  nausea  and 
vomiting  are  so  common  in  the  early  months  that  they  are  recognized 
as  the  usual  accompaniments  of  the  pregnant  state.  The  nausea  and 
vomiting  are  most  common  during  the  second  and  third  months,  and 
usually  disappear  gradually  during  the  fourth  month.  In  some  women 
the  nausea  begins  almost  immediately  after  impregnation.  At  the  present 
day,  if  the  nausea  and  vomiting  persist  for  any  great  length  of  time,  the 
condition  ceases  to  be  regarded  as  physiological,  and  is  looked  upon  as 
toxemia,  as  will  be  discussed  later. 

The  nausea  and  gagging  with  or  without  vomiting  is  most  apt  to  occur 
on  rising  in  the  morning,  perhaps  on  brushing  the  teeth,  and  throughout 
the  day  it  is  rather  more  likely  to  occur  when  the  stomach  is  empty,  the 
effort  at  vomiting  simply  resulting  in  the  expulsion  of  glairy  mucus. 

It  is  a  common  experience  with  pregnant  women  during  the  early 
months  to  reject  their  breakfast  soon  after  taking  it,  yet  be  able  to  retain 
and  digest  the  other  meals  of  the  day.  Although  it  is  common  during 
the  first  three  months  for  pregnant  women  to  lose  in  nutrition  and  weight, 
after  three  months  the  rule  is  a  gain  in  appetite  and  general  nutrition 
and  an  increase  of  adipose  tissue,  especially  during  the  later  weeks, 
amounting  at  the  close  of  pregnancy,  often  to  a  gain  of  10  to  15  pounds 
irrespective  of  the  weight  of  the  enlarged  uterus  and  its  contents. 

According  t-o  Williams  this  gain  in  weight  is  chiefly  due  to  a  diminished 
excretion  of  water.  Slemmons  at  the  Johns  Hopkins  Hospital  found  this 
excretion  during  pregnancy  to  be  only  50  to  75  per  cent,  of  the  water 


132 


CHANGES  PRODUCED  IN  MATERNAL  ORGANISM 


ingested.  In  a  case  with  a  dead  fetus  it  Avas  as  high  as  93  per  cent.^ 
about  the  normal  for  non-pregnant  women. 

The  appetite  of  a  woman  during  pregnancy,  especially'  during  the  early 
months,  is  very  apt  to  be  capricious;  her  likes  and  dislikes  being  often 
directly  at  variance  with  her  normal  tastes.  The  increased  nutrition  oc- 
curring during  pregnancy  seems  to  be  a  wise  provision  of  nature  for  the 
drain  to  which  the  woman  is  to  be  subjected  during  lactation.  There 
seems  to  be  a  storage  of  nitrogen  in  the  bod>'  during  pregnancy.  This 
is  shown  by  a  diminished  amount  of  nitrogen  in  the  urine.  This  nitrogen 
may  be  used  as  proteid  material  in  the  develo])ment  of  the  fetus  and 
placenta  and  in  the  increased  growth  of  the  maternal  organs. 

Not  only  is  there  less  nitrogen  excreted  in  the  urine  during  pregnancy 
but  it  is  excreted  in  different  ratio;  as  is  shown  on  page  418,  the  average 
urea  nitrogen  being  decreased  while  the  ammonia  nitrogen  is  usually 
increased.  As  the  pregnant  woman  has  to  excrete  alike  for  herself  and 
her  fetus,  all  her  excretory  organs  are  taxed  beyond  the  normal  and  the 
importance  of  their  ready  action  is  apparent. 

The  Blood  and  Circulation. — While  the  blood  of  a  healthy  pregnant 
woman  does  not  differ  markedly  from  that  of  the  non-pregnant  state, 
certain  variations  exist  which  are  worthy  of  note.  There  is  a  moderate 
hydremia,  especially  in  the  latter  months,  as  shown  by  its  lowered  specific 
gravity;  there  is  an  increase  in  its  fibrin  factors  and  a  decrease  in  its 
albuminous  content.  The  amount  of  hemoglobin  and  the  number  of 
red  corpuscles  remain  practically  normal.  There  is  a  moderate  leuko- 
cytosis in  pregnancy  which  reaches  its  maximum  during  labor  and  then 
gradually  declines  to  normal  on  about  the  tenth  day  as  is  shown  by  the 
following  table  which  represents  examinations  of  the  blood  of  100  women 
at  the  Sloane  Hospital  taken  before  labor,  during  labor,  on  the  third  and 
the  tenth  day  of  the  puerperium. 

LEUKOCYTE    COUNT    IX    ONE    HUNDRED    PREGNANT    AND    PUERPERAL 

WOMEN. 


Polymorpho- 
Duclear. 
Per  cent. 


Large  mono- 
nuclear 


Lympho- 
cytes. 


Eosino- 
philes. 


Transi- 
tional. 


Total. 


During  pregnancy. 
During  labor 
Third  day  of  puerperium 
Tenth  day  of  puerperium 


71 


72 
65 


3.2 
2.5 
.3.0 
3.5 


21 
17 
21 
27 


0.8 
0.7 
1.4 
1.5 


4.0 
2.8 
3.0 
3.0 


10,600 
12,800 
11,700 
10,.300 


To  determine  whether  the  leukocyte  count  was  affected  by  lactation, 
the  blood  of  15  women,  who  for  different  reasons,  as  for  instance  the  loss 
of  the  baby  or  previous  inability  to  nurse,  did  not  attempt  lactation,  was 
examined  on  the  third  and  tenth  day  of  the  puerperium  with  the  following 
results: 


Third  day,  15  cases 
Tenth  day,  15  cases 


Polymorpho- 
nuclear. 
Per  cent. 


Large  mono- 
nuclear. 


7.3 
64 


Lympho- 
cytes. 


19 
27 


Eosino- 
philes. 


Transi- 
tional. 


Total 


12,000 
9,700 


GENERAL  CHANGES  DURING  PREGNANCY  133 

It  is  seen  from  the  above  that  the  polymorphonuclear  cells  are  relatively 
increased  during  the  latter  part  of  pregnancy,  reaching  their  maximum 
during  labor  and  gradually  falling  to  normal  by  the  tenth  day. 

The  large  mononuclear,  lymphocytes,  eosinophile  and  transitional  cells 
are  not  materially  affected  except  as  they  are  diluted  either  more  or  less 
by  the  number  of  polymorphonuclear  cells,  their  percentage  diminishing 
as  the  polymorphonuclear  cells  increase,  and  increasing  again  as  these 
return  to  normal. 

The  leukocyte  count  in  the  women  who  did  not  nurse  was  practically 
the  same  as  in  those  in  active  lactation. 

Disturbances  of  the  circulation  with  headache,  palpitation  of  the  heart, 
and  dyspnea  are  not  uncommon,  and  during  the  early  months  are  often 
neurotic  in  origin,  although  aggravated  by  an  anemic  condition  of  the 
blood.  During  the  latter  months  the  circulation  is  often  disturbed  by 
upward  pressure  of  the  growing  uterus  upon  the  diaphragm  and  heart. 

Owing  to  the  hydremia  and  impeded  circulation  during  pregnancy,  a 
moderate  amount  of  edema  is  not  uncommon.  If  it  is  only  moderate, 
however,  and  the  urine  is  normal  it  need  not  occasion  alarm.  An  extreme 
anemia  always  needs  attention. 

Blood-pressure  in  Pregnancy. — The  blood-pressure  of  the  normal  preg- 
nant woman  differs  but  little  from  that  in  the  non-pregnant  woman.  In 
normal  pregnancy  it  usually  ranges  between  110  and  120.  In  a  consecu- 
tive series  of  564  normal  pregnant  women  at  the  Sloane  Hospital  the 
average  was  113.  In  many  cases  it  is  found  as  low  as  90  and  occasionally, 
especially  in  elderly  pregnant  patients,  it  is  found  as  high  as  135  to 
140.  The  importance  of  the  observation  of  the  blood-pressure  of  preg- 
nant patients  will  be  emphasized  under  the  management  of  normal 
pregnancy,  and  in  the  discussion  of  "Toxemia  of  Pregnancy"  attention 
will  be  called  to  the  fact  that  a  blood-pressure  above  140  should  always 
be  looked  upon  with  suspicion. 

Respiration. — The  dyspnea  which  sometimes  occurs  during  the  early 
months  has  already  been  spoken  of  as  being  often  of  neurotic  origin. 
During  the  later  months  of  pregnancy,  on  account  of  the  shortened  longi- 
tudinal diameter  of  the  thorax  by  upward  pressure  upon  the  diaphragm, 
respiration  is  often  mechanically  embarrassed.  The  transverse  diameter 
of  the  lower  part  of  the  thorax  is  somewhat  increased,  but  this  additional 
room  for  lung  expansion  does  not  equal  the  increased  demand  in  furnish- 
ing oxygen  and  getting  rid  of  carbon  dioxide  (CO2)  for  both  mother  and 
child.  During  the  last  two  weeks  of  pregnancy,  on  account  of  the  settling 
into  the  pelvis  of  the  uterus  and  its  contents,  respiration  becomes  easier. 
This  is  sometimes  spoken  of  as  "lightening." 

The  Nervous  System. — ^From  the  beginning  to  the  end  of  pregnancy, 
though  especially  in  the  early  months,  the  nervous  system  of  the  preg- 
nant woman  is  apt  to  show  marked  changes.  Her  disposition  may  be 
completely  altered  and  her  power  of  nerve  control  almost  lost.  Her 
nervous  system  seems  to  be  at  high  tension,  and  under  excitation,  which 
in  the  non-pregnant  state  would  scarcely  disturb,  she  may  become 
emotional,  irritable  or  even  unreasonable.    Certain  it  is  that  husbands 


134  CHANGES  PRODUCED   IN   MATERNAL  ORGANISM 

jiiul  friends  should  make  allowances  for  the  dispositions  of  women  (hiring;' 
pregnancy  and  causes  of  irritation  should  be  as  far  as  possil^le  exchided 
during  this  time. 

Neuralgia  in  dift'erent  parts  of  the  body,  especially  about  the  face,  in 
the  back,  and  down  the  thighs  is  quite  common  in  pregnancy,  as  a  result 
of  the  hydremia,  the  pressure,  and  the  neuroses  incident  to  tlie  condition. 

The  Liver  and  Spleen. — The  liver  and  spleen  are  usually  increased 
in  size  and  fatty  degeneration  may  occur  in  both  viscera. 

The  Kidneys. — The  kidneys,  like  the  liver  and  spleen,  are  usually 
enlarged  during  pregnancy  and  their  functional  activity  greatly  increasecl. 
The  urine  is  normally  increased  somewhat  in  amount  with  a  specific 
gravity  of  about  1013.^  This  increased  amount  of  urine  is  probably  in 
part  due  to  the  large  amount  of  water  patients  are  advised  to  drink. 

The  chlorides,  phosphates  and  sulphates  are  usually  diminished,  as  is 
also  the  nitrogen  output.  In  the  later  weeks  of  pregnancy,  and  espe- 
cially during  lactation,  lactose  not  infrequently  appears;  occasionally 
glucose  occurs  which  may  be  due  to  faulty  metabolism  or  to  diabetes 
and  will  be  considered  later.  In  quite  a  large  percentage  of  pregnant 
women  a  transient,  slight  albuminuria  appears  without  other  symptoms. 
According  to  Sondern^  this  frequency  is  as  high  as  50  per  cent. 

The  Heart. — Until  recently  there  was  a  belief  that  the  heart  is  enlarged 
during  pregnancy.  Attempts  to  ascertain  this  have  followed  general 
lines,  namely:  (1)  By  percussion  or  auscultation  of  the  living  woman; 
(2)  by  measuring  the  walls  of  the  heart  at  autopsy;  (3)  by  weighing  the 
heart  at  autopsy;  and  (4)  by  inference  from  studying  the  blood-pressure 
in  pregnancy. 

1.  In  1827,  Larcher,^  finding  an  increased  area  of  cardiac  dulness, 
concluded  the  heart  was  enlarged.  Gerhardt"*  showed  this  increased  area 
of  dulness  was  due  to  the  upward  displacement  of  the  heart  by  the  grow- 
ing uterus,  and  not  to  hypertrophy.  This  increased  area  of  dulness 
disappears  after  delivery.'^  In  cases  when  there  is  marked  separation  of 
the  recti  muscles  of  the  abdomen,  allowing  the  uterus  to  sag  forward, 
and  lessening  the  tendency  to  upward  pressure  on  the  heart,  this  in- 
creased area  is  less  marked.*^ 

2.  Larcher'^  and  Ducrest^  found  the  average  thickness  of  the  left 
ventricular  wall  in  pregnancy  greater  than  10  mm.  supposed  to  be  the 
average  for  normal  hearts  of  the  non-pregnant  women,^  and  claimed 
hypertrophy.  BuhP'^  found  the  conclusions  wrong,  as  the  average  was 
16  and  17  mm.  and  not  10  mm.    He  claimed  no  hypertrophy. 

'  Urine  in  Normal  Pregnancy  (Mathews),  Amer.  Jour.  Med.  Sciences,  June,  1906. 

2  The  Urine  in  Pregnancy,  Bulletin  of  the  Lying-in  Hospital,  New  YoVk,  December,  190G. 

'  Quoted  from  Stengel  and  Stanton,  Archiv.  generales  de  med.,  1859,  i,  291;  also  from 
Williams,  from  Ribemont-Dessaignes  and  Lepage,  Precis  d'obstetrique,  Paris,    1894. 

^  De  situ  et  magnitudine  cordis  gravidarum,  Jena,  1862. 

^  Stengel  and  Stanton,  The  Heart  and  Circulation  in  Pregnancy  and  the  Puerperium, 
Univ.  of  Penna.  Med.  Bull.,  September,  1904,  p.  202. 

•■  Larcher,  loc.  cit.  '  Loc  cit. 

•*  Quoted  from  Stengel  and  Stanton,  Archiv.  generales  de  med.,  S.  7,  F.  .5. 

s  Bizot,  Quoted  from  Stengel  and  Stanton. 

'"  Quoted  from  Stengel  and  Stanton,  Delaficld  and  Pruddcn,  Handbook  of  Path.  Anatomy, 
1901. 


GENERAL  CHANGES  DURING  PREGNANCY  135 

3.  Miiller^  and  Lohlein^  found  no  increase  in  weight;  Dreysel/  a  slight 
increase.  Stengel  and  Stanton,  of  the  University  of  Pennsylvania/  taking 
the  findings  of  15  different  authors,  established  the  average  weight  of 
the  normal  heart  of  the  non-pregnant  woman  as  263  gms.  After  weigh- 
ing a  series  of  hearts  from  pregnant  women  they  found  no  increase. 

4.  Many  have  held  that  there  was  an  increased  blood-pressure  during 
pregnancy,  and  therefore  the  heart,  having  more  work  to  do,  must  become 
larger.  Stengel  and  Stanton^  by  a  series  of  experiments  showed  there 
was  no  increase  of  blood-pressure  at  any  time  during  pregnancy,  and  in 
labor  only  during  the  second  stage. 

Williams^  thinks  there  is  a  slight  increase  of  blood-pressure  during 
pregnancy,  and  therefore  a  hypertrophy. 

It  is  difficult  to  arrive  at  a  conclusion.  None  of  the  methods  are  con- 
clusive. Physical  examination,  if  it  does  not  show  a  hypertrophy,  at 
least  does  not  preclude  it,  as  a  moderate  hypertrophy  would  be  hard  to 
detect,  especially  with  the  enlarged  breasts. 

Measuring  and  weighing  the  hearts  are  not  certain  methods,  for  many 
of  the  hearts  available  are  diseased,  and  therefore  enlarged  from  causes 
other  than  pregnancy.  Moreover,  the  weight  of  the  heart  depends  on 
the  amount  of  surrounding  tissue  removed. 

Arguments  based  on  the  blood-pressure  are  only  inferential  and  not 
conclusive. 

Hence  the  question  is  still  undecided,  but  the  burden  of  proof  points 
to  no  great  enlargement  of  the  heart  during  pregnancy. 

The  Thyroid  Gland  in  Pregnancy. — The  ancient  tradition  that  a 
woman's  neck  enlarges  at  onset  of  the  first  menses,  at  each  succeeding 
reappearance  of  them  and  during  pregnancy  has  found  support  in  recent 
investigations  which  explain  this  enlargement  by  the  increase  in  the 
size  of  the  thyroid  gland  on  these  occasions.  The  occurrence  of  such 
increase  during  pregnancy  is,  however,  variously  stated  by  different 
observers.  Thus  Freund  observed  augmentation  in  the  volume  of  the 
gland  in  45  out  of  50  women  examined  by  him.  Lange  confirmed  this 
observation  and  showed  that  a  clinically  demonstrable  enlargement  of 
the  gland  does  not  exist  in  the  first  three  months  of  pregnancy;  it  appears 
among  the  multigravidse  as  early  as  the  fifth  month,  while  among  primi- 
gravidse  it  is  usually  not  evident  until  the  sixth  month.  Markoe  and 
Wing  have  quite  recently  observed  1586  pregnant  women  and  have  found 
among  them  132  goitres  or  8.3  per  cent.  It  occurred  in  83  out  of  852 
primigravidse  (9.7  per  cent),  and  in  49  of  734  multigravidse  (6.7  per  cent.). 
In  some  of  these  cases  goitres  have  existed  since  childhood,  in  others 
they  appeared  at  onset  of  menstruation,  in  still  others  between  this 
period  and  marriage.     In  20  cases  among  the  primigravidse  and  in  17 

1  Quoted  from  Hirst,  Muller's  Handbook,  vol.  i;  also  from  Stengel  and  Stanton,  Die 
Massenverhaltnisse  des  Mensch.  Herzens,  1883. 

2  Ueber  das  verhalten  des  Herzens  bei  Schwangeren,  Zeitschr.  f.  Geb.  u.  Frauenkrank- 
heiten,  1876,  i,  482-516. 

3  Quoted  from  Stengel  and  Stanton,  Inaug.  Dissert.,  Miinchen,   1891. 

<  Stengel  and  Stanton,  loc.  cit.  ^  Loc.  cit, 

«  Obstetrics,  1912  ed.,  p.  177. 


136  CHANGES  PRODUCED  IN  MATERNAL  ORGANISM 

inultigravidie  it  positi^'eIy  appeared  during  j)regnancy.  (Jreat  variations 
were  noted  both  in  the  month  of  pregnaney  and,  among  the  mnltigravidae, 
in  the  number  of  the  pregnancy,  in  which  the  thyroid  was  found  enhirged. 

Several  case  reports  of  preexisting  goitre  enlarging  during  pregnancy 
have  been  published.  Some  of  the  authors  state  that  the  enlargement 
involved  the  non-cystic  portions  of  the  gland.  Cases  have  been  reported 
in  which  the  enlargement  of  a  preexisting  goitre  and  even  of  a  previously 
normal  thyroid  has  been  sufficiently^'  marked  to  cause  obstruction  in 
breathing  and  occasionally  necessitate  operation. 

The  enlarged  thyroid  usually  decreases  rapidly  after  labor,  complete 
subsidence  being  noted  in  the  great  majority  of  cases  within  two  weeks. 
Occasionally  a  more  or  less  marked  enlargement  of  the  gland  remains 
permanently. 

It  is  fairly  certain  that  the  increase  in  size  of  the  thyroid  is  accom- 
panied by  increased  function.  The  few  microscopic  examinations  that 
have  been  published  show  that  in  addition  to  hyperemia  there  appear 
such  evidences  of  hyperfunction  as  increase  in  the  colloid  substance 
and  in  the  intracellular  granules.  Lange  has  noted  that  absence  of  the 
enlargement  of  the  thjToid  is  frequently  accompanied  by  such  untoward 
symptoms  as  albuminuria,  etc.  Freund  has  thought  that  the  adminis- 
tration of  thyroid  substance  during  pregnancy  had  a  beneficial  effect. 
Lange  has  shown,  experimentally,  by  removing  large  portions  of  the 
thyroid  in  cats,  that  insufficiency  of  the  thyroid  leads  to  pathological 
states  in  pregnancy.  These  and  similar  observations  have  led  to  the 
establishment  of  a  theory  according  to  which  a  certain  proportion  of 
the  toxemias  of  pregnancy  are  due  to  alteration  in  the  function  of  this 
gland,  that  is  to  dysthyroidism,  whether  this  alteration  be  marked  by 
excessive  or  insufficient  activity.  This  aspect  of  the  question  will  be 
considered  in  the  discussion  of  the  Toxemias  of  Pregnancy. 

In  conclusion  it  may  be  stated  that  the  thyroid  gland  is  usually 
increased  in  size  during  pregnancy,  and  in  women  whose  thyroids  are 
already  enlarged  pregnancy  often  greatly  stimulates  the  growth.  Lange, 
in  1899,  found  an  increase  in  the  size  of  this  gland  in  108  out  of  133 
women  observed  during  the  last  three  months  of  pregnancy. 

The  Bladder  and  Rectum. — Throughout  pregnancy  the  functions  of 
the  bladder  and  rectum  are  more  or  less  interfered  with  by  the  pressure 
of  the  growing  uterus.  Disturbance  of  the  bladder  is  usually  most  marked 
during  the  first  two  months  and  during  the  last  two  weeks,  during  both 
of  which  periods  the  uterus  with  its  contained  fetus  settles  in  the  pelvis. 

Throughout  pregnancy  the  space  allowed  for  distention  of  the  bladder 
is  limited  so  that  frequent  micturition  and  irritability  of  the  bladder 
are  common.  As  a  result  of  the  constantly  increasing  pressure  upon  the 
rectum  more  or  less  constipation  is  to  be  expected  during  pregnancy, 
especially  in  women  with  a  constipated  tendency.  On  account  of  the 
obstruction  to  venous  return,  hemorrhoids  are  not  infrequent. 

The  Skin. — Under  the  influence  of  pregnancy  two  marked  changes 
take  place  in  the  skin:  (a)  An  increased  deposit  of  pigment;  (b)  the 
changes  resulting  from  stretching. 


GENERAL  CHANGES  DURING  PREGNANCY 


137 


(a)  Pigmentation. — One  of  the  characteristic  changes  occurring  at 
about  the  middle  of  pregnancy  is  the  increased  deposit  of  pigment  in 
different  parts  of  the  bod\'.  This  deposit  is  most  marked  upon  the  breasts 
(giving  the  primary  and  secondary  areolae  already  described),  the  abdo- 
men, and  the  face.  Brunettes  show  this  increased  deposit  much  more 
than  blondes. 

On  the  abdomen  the  deposit  of  pigment  occurs  along  the  median  line 
from  umbilicus  to  s^Tnphysis  pubis  (see  Fig.  108),  sometimes  reaching 
from  umbilicus  to  ensiform  cartilage. 

On  the  face  it  is  most  apt  to  occur  on  the  forehead  and  cheeks,  sometimes 
appearing  in  large  blotches  called  chloasmata  which  are  very  disfigur- 
ing (see  Fig.  109).  Most  of  the  increased  pigmentation  disappears  after 
parturition  but  some  usually  remains,  especially  upon  the  breasts  and 
abdomen. 


Fig.  108. — Pigmentation  along  median  line  of  abdomen;  also  abdominal  striae. 

(b)  Strise. — ^As  a  result  of  overstretchmg  of  the  skin  during  pregnancy, 
especially  during  the  last  three  months,  strise  appear  upon  the  breasts 
(already* described),  upon  the  abdomen,  especially  at  the  sides  and  lower 
part,  aiid  down  the  thighs  (see  Fig.  110).  These  strise  are  due  to  a 
separation  of  the  deeper  elastic  fibers  of  the  cutis  and  the  formation  of 
cicatricial  tissue.  At  first  they  are  brownish  or  piu-plish  in  color  but 
after  parturition  the  color  fades,  although  markings  remain  as  permanent 
silvery  strise.  The  presence  of  these  old  strise  do  not  necessarily  prove 
the  preexistence  of  a  pregnancy,  as  they  can  occur  from  distention  of 
the  skin  bv  ascites  and  may  occur  in  men  as  well  as  in  women. 


138  CHAXGES   PRODUCED   IX    MATERXAL  ORG  AX  ISM 


Fig.  109. — Pigmentation  of  the  face  due  to  pregnancy. 


Fig.  110. — Striae  of  breasts,  abdomen,  and  thighs.     This  photograph  was  taken  soon 

after  delivery. 


GENERAL  CHANGES  DURING  PREGNANCY  139 

The  sebaceous  and  sweat  glands  of  the  skin  are  stimulated  to  increased 
activity  by  pregnancy. 

Up  to  the  sixth  month  of  pregnancy  the  umbihcus  gradually  lessens  in 
depth.  At  six  months  it  is  usually  level  with  the  surrounding  skin  and 
after  that  gradually  protrudes. 

Posture.  —  During  the  latter  months  of  pregnancy,  owing  to  the 
increased  abdominal  weight,  the  head  and  shoulders  of  the  pregnant 
woman  are  thrown  backward,  in  standing  and  walking,  so  as  to  main- 
tain her  equilibrium. 

Bones  and  Teeth. — There  is  a  slight  increase  in  the  mobility  at  the 
pelvic  articulations  during  pregnancy.  This,  as  a  rule,  is  insufficient  to 
affect  locomotion. 

In  certain  rare  cases,  however,  the  mobility  at  the  symphysis  is  so 
great  as  to  make  walking  difficult. 

On  the  inner  surface  of  the  cranial  bones  of  pregnant  women  there 
have  been  observed  small,  irregular  outgrowths  of  new  bone.  These  were 
first  foimd  by  Rokitansky  and  called  by  him  "puerperal  osteoph^^tes." 
Their  significance  is  not  known. 

The  teeth  during  pregnancy  are  apt  to  decay  more  rapidly  than  in  the 
non-pregnant  state,  and  this  gave  rise  to  the  old  saying,  "For  every  child 
a  tooth."  ^ 


CHAPTER  IV. 

THE  SYIMPTOMS  AND  SIGNS  OF  PREGNANCY.    THEIR 
RELATIVE  VALUE  IN  DIAGNOSIS. 

For  convenience  of  description  the  symptoms  of  pregnancy  will  be 
grouped  into:  (a)  Those  occurring  during  the  first  three  months,  and 
(b)  Those  occurring  during  the  last  six  months. 

SYMPTOMS  AND  SIGNS  DURING  THE  FIRST  THREE  MONTHS. 

One  of  the  first  symptoms  of  pregnancy,  and  the  one  for  which  every 
married  woman  is  always  more  or  less  upon  the  watch,  is  cessation  of 
menstruation.  While  exceptionally  a  menstrual  flow  occurs  after  impreg- 
nation has  taken  place,  the  rule  is  ivith  the  occurrence  of  pregnancy  men- 
struation ceases.  The  usual  experience  is  that  impregnation  occurs 
soon  after  a  regular  menstruation;  that  before  the  time  for  the  next 
menstruation  the  impregnated  ovum  has  reached  and  has  become 
imbedded  in  the  endometrium,  and  no  menstruation  appears.  One  of 
the  explanations  of  menstruation  appearing  after  impregnation  has 
occurred  is  as  follows : 

Instead  of  impregnation  occurring  just  after  a  regular  menstruation, 
it  may  not  occur  until  just  prior  to  the  succeeding  menstrual  period. 
In  this  case  menstruation  may  not  be  checked,  although  it  is  usually 
lessened  in  amount  and  changed  in  character.  Although  in  accordance 
with  the  established  habit  of  a  periodical  loss  of  blood  there  may  appear 
for  a  few  months  a  bloody  discharge,  certain  it  is  that  after  the  third 
month  when  the  decidua  capsularis  (reflexa)  covering  the  ovum  is 
brought  in  apposition  with  the  decidua  parietalis  (vera)  of  the  opposite 
side  of  the  uterine  cavity,  no  true  menstruation  can  occur.  The  bloody 
discharges  reported  by  women  as  occurring  during  pregnancy  usually 
mean  either  an  endometritis;  a  polypus  of  the  cervix;  a  low  attachment 
of  the  chorionic  villi  or  of  the  placenta.  "We  have  then  the  well-estab- 
lished rule  that  when  a  healthy  married  woman,  living  with  her  husband, 
during  active  menstrual  life,  ceases  to  menstruate  she  is  probably  pregnant. 
This  is  one  of  the  most  valuable  symptoms  in  arriving  at  the  diagnosis 
of  pregnancy  in  the  early  months. 

Certain  exceptions  occur,  however,  which  must  be  considered  and 
appreciated.  The  occurrence  of  an  occasional  bloody  vaginal  discharge 
after  the  beginning  of  pregnancy  has  already  been  mentioned.  On  the 
contrary,  there  are  numerous  causes  of  amenorrhea  aside  from  preg- 
nancy. Among  these  causes  anemia  and  phthisis  act  most  frequently. 
Other  common  causes  of  amenorrhea  or  delayed  menstruation  are  changes 

(I40p 


SYMPTOMS  AND  SIGNS  DURING  FIRST   THREE  MONTHS    141 

of  climate,  obesity,  sudden  chilling  near  the  time  of  the  menstrual  period, 
and  violent  mental  emotion.  The  fear  of  pregnancy  after  illicit  inter- 
course; the  expectation  or  dread  of  pregnancy  in  the  newly  married; 
these  at  times  seem  to  have  the  effect  of  postponing  the  menstrual  period. 
Some  women  are  so  irregular  in  their  menstrual  habit  that  absence  of 
menstruation  even  for  several  months  is  a  matter  of  no  importance. 
Furthermore,  the  occasional  occurrence  of  pregnancy  before  menstrua- 
tion has  ever  occurred,  and  also  after  the  establishment  of  the  menopause, 
and  the  occurrence  of  pregnancy  during  the  physiological  amenorrhea 
of  lactation — all  these  exceptional  occurrences  prove  that  the  symptom 
of  cessation  of  menstruation  in  the  diagnosis  of  pregnancy  has  many 
limitations  to  its  value. 

Nausea  and  Vomiting. — The  occurrence  of  nausea  and  vomiting 
during  the  early  months  of  pregnancy  has  already  been  referred  to,  and 
when  associated  with  the  x^essation  of  menstruation  is  a  presumptive 
symptom  of  considerable  value.  It  occurs  most  usually  in  the  morning 
on  rising  or  after  breakfast  and  during  the  second  and  third  months  of 
pregnancy.  Exceptionally  it  begins  within  a  few  days  after  impregna- 
tion and  continues  throughout  the  whole  of  pregnancy. 

Although  in  conjunction  with  other  symptoms,  it  is  of  considerable 
value  in  the  diagnosis  of  pregnancy,  when  taken  by  itself  its  value  is 
slight.  As  it  arises  as  a  reflex  symptom  from  stretching  of  the  uterine 
muscle  and  nerves  and  from  pressure,  it  may  arise  from  various  patho- 
logical conditions  in  the  pelvis.  Its  gastric  causes,  as  in  the  non-pregnant 
state,  are  also  frequent. 

Salivation. — With  the  nausea  of  pregnancy  there  is  often  an  increase 
in  the  salivary  secretion  which  at  times  becomes  excessive  and  very 
annoying. 

Breast  Symptoms. — Although  the  changes  in  the  breasts  resulting 
from  pregnancy  are  more  or  less  permanent  and  in  a  multigravida  are 
of  much  less  value  in  diagnosis  than  in  a  primigravida,  in  every  preg- 
nancy they  are  characteristic. 

As  early  as  the  second  month  the  breasts  usually  feel  fuller  and  firmer 
to  the  patient  and  on  palpation  the  knotted  cords  formed  by  the  develop- 
ing ducts  can  usually  be  detected.  The  increased  pigmentation  and 
elevation  of  the  primary  areola  and  the  development  of  Montgomery's 
tubercles  appear  at  this  time.  During  the  third  month  a  little  colostrum 
can  usually  be  expressed  from  the  nipple. 

These  breast  symptoms  when  present  in  a  primigravida  are  a  very 
strong  presumptive  evidence  of  pregnancy.  It  must  be  remembered, 
however,  that  in  a  multigravida  they  may  have  persisted  from  a  pre- 
vious recent  pregnancy,  and  furthermore  various  uterine  and  ovarian 
disorders  may  produce  similar  symptoms,  including  even  the  possibility 
of  expressing  colostrum  from  the  nipple. 

The  Violet  Hue  of  Vagina  and  Cervix. — During  the  third  month,  and 
sometimes  earlier  as  a  result  of  venous  congestion,  the  vagina  and  vaginal 
portion  of  the  cervix  present  a  violet  hue  which  is  quite  characteristic 
of  pregnancy.    Remembering,  however,  that  this  deepening  of  color  is  due 


142 


THE  SYMPTOMS  AND  SIGNS  OF  PREGNANCY 


to  venous  congestion  it  is  readily  seen  that  anything  obstructing  venous 
return  such  as  pelvic  inflammation,  tumors,  etc.,  may  produce  simihir  signs. 


Fig.   111. — Asymmetrical  pregnant  uterus. 


Fig.   112. — Hegar's  sign  of  pregnancy. 


Softening  of  the  Cervix  and  Uterine  Body. — During  the  second  month 
the  cervix  is  found  on  ])alpation  to  have  begun  around  the  external  os 


SYMPTOMS  AXD  SIGNS  DURING  LAST  SIX  MONTHS         143 

a  softening  which  is  gradually  to  involve  the  whole  cervix.  Nor  is  this 
softening  confined  to  the  cervix.  It  has  already  been  stated  (see  page  123) 
that  beginning  with  the  second  month  the  uterine  body  becomes 
more  spherical.  There  is  a  bulging  and  softening  of  the  uterine  body 
which  may  be  symmetrical  and  the  projection  easily  felt  per  vaginam, 
a  little  above  the  cervix,  usually  more  distinct  on  the  anterior  wall  on 
account  of  the  anteflexion.  On  the  other  hand  the  bulging  and  softening 
may  be  asymmetrical  and  correspond  to  the  location  of  the  developing 
ovum.  In  the  latter  case  the  furrow  separating  the  bulging  softened 
portion  from  the  remainder  of  the  uterus  (see  Fig.  Ill)  may  suggest  the 
possibility  of  the  gestation  being  ectopic. 

Between  the  bulging  uterine  body  and  the  cervix  the  lower  uterine 
segment  becomes  so  soft  and  compressible  that  the  bimanual  examina- 
tion gives  the  impression  that  the  fingers  on  the  anterior  and  posterior 
wall  of  the  uterus  can  be  brought  nearly  in  apposition  (see  Fig.  112). 
This  is  called  Hegar's  sign  of  pregnancy,  and  when  clearly  obtained  is 
of  considerable  value  in  diagnosis.  It  must  be  remembered,  however, 
that  the  softening  of  the  uterus  resulting  from  inflammation  may  give 
signs  somewhat  resembling  the  Hegar's  sign  of  pregnancy. 

The  symptoms  and  signs  of  pregnancy  during  the  first  three  months, 
the  amenorrhea,  the  nausea  and  vomiting,  the  breast  changes,  the  violet 
hue  of  vagina  and  cervix,  and  the  softening  of  the  cervix  and  uterus, 
although  of  strong  presumptive  evidence,  especially  when  several  are 
conjoined,  are  none  of  them  positive  proof  of  pregnancy  when  taken 
individually.  It  is  found  that  any  one  of  them  may  be  simulated  by 
the  results  of  inflammation  or  disease  and  therefore  the  diagnosis  of 
pregnancy  prior  to  the  fourth  month  should  be  very  guarded.  It  is  only 
by  finding  several  of  the  above  symptoms  conjointly  present  that  the 
physician  is  justified  in  stating  his  diagnosis. 

SYMPTOMS  AND  SIGNS  OF  PREGNANCY  DURING  THE  LAST  '^ 

SIX  MONTHS. 

During  this  period  occur  three  so-called  positive  symptoms  of  preg- 
nancy, all  being  present  during  the  first  three  months  of  the  six. 

1.  Ballottement. 

2.  Fetal  movements. 

3.  Fetal  heart  sounds. 

In  addition  to  these  positive  symptoms  there  are  several  of  more  or 
less  presumptive  value:  Eiflargement  of  the  uterus;  uterine  souffle; 
funic  souffle;  secondary  areola;  general  increase  of  pigmentation;  inter- 
mittent uterine  contractions;  changes  in  the  cer^•ix. 

Ballottement. — If  the  woman  is  placed  in  the  dorsal  position  (better 
with  head  and  shoulders  elevated)  and  one  or  two  fingers  placed  in  the 
anterior  vaginal  fornix,  a  gentle  tap  with  the  finger  between  the  fourth 
and  seventh  month,  will  usually  cause  a  displacement  of  the  fetus  upward 
through  the  liquor  amnii  only  to  be  followed  by  a  return  to  the  pre- 
senting finger.    This  displacement  and  return  is  called  "ballottement" 


144  THE  SYMPTOMS  AND  SIGNS  OF  PREGNANCY 

and  is  considered  a  positive  symptom  of  pregnancy.  In  the  hands  of  a 
skilled  observer  and  taken  in  conjunction  with  other  symptoms  it  may 
be  so  regarded,  but  it  should  not  be  forgotten  that  a  small  fibroid  or 
ovarian  cyst  with  a  long  pedical  or  a  vesical  calculus  might  respond  to 
the  finger  tap  in  a  way  which  would  deceive  a  careless  examiner.  Bal- 
lottement  is  onl\'  obtained  after  the  fetus  is  large  enough  to  impart 
sensation  to  the  finger,  therefore  usually  not  before  the  fourth  month  and 
as  a  rule  not  after  the  early  part  of  the  seventh  month,  after  which  the 
fetus  too  nearly  fills  the  uterine  cavity.  With  twin  pregnancy,  placenta 
previa  and  scanty  liquor  amnii,  ballottement  is  usually  difficult  or 
impossible  to  obtain. 

Fetal  Movements. — At  about  the  middle  of  pregnancy,  viz.,  about 
four  and  a  half  months,  the  uterus  has  risen  sufficiently  out  of  the  pelvis 
to  come  in  contact  with  the  anterior  abdominal  wall  and  movements  of 
the  fetus  are  transmitted  through  it  to  the  mother  and  later  to  the  hand 
of  the  examiner  placed  upon  it.  The  transmission  of  the  sensation  of 
fetal  movements  to  the  mother  is  called  "feeling  life"  or  "quickening," 
and  as  it  usually  occurs  at  about  the  middle  of  pregnancy,  i.  e.,  four  and 
a  half  months,  it  is  of  some  value  in  determining  the  probable  date  of 
confinement  in  cases  where  the  date  of  the  last  menstruation  cannot  be 
utilized  for  that  purpose,  as  when  impregnation  occurs  during  a  period 
of  amenorrhea,  either  the  result  of  disease,  or  the  physiological  amenor- 
rhea of  lactation.  In  multigravidse  the  sensation  of  "  feeling  life  "  is  often 
detected  at  an  earlier  period  in  pregnancy  than  in  primigravidse  who 
experience  it  for  the  first  time. 

The  sensation  of  fetal  movements  is  regarded  as  a  positive  symptom 
of  pregnancy,  but  attention  must  be  directed  to  the  fact  that  in  women 
extremely  desirous  of  progeny,  and  in  whom  hope  has  been  aroused  after 
years  of  disappointment,  movements  of  gas  in  the  intestine  have  been 
mistaken  for  fetal  movements. 

Fetal  Heart  Sounds. — Of  all  the  signs  indicative  of  pregnancy  the 
detection  of  the  fetal  heart  sounds  is  the  most  positive.  They  were  first 
recorded  as  heard  by  Mayor,  of  Geneva,  in  1818,  and  since  then  more 
and  more  importance  has  been  placed  upon  them  not  only  as  an  indica- 
tion of  the  existence  of  pregnancy,  but  in  the  diagnosis  of  multiple 
pregnancy,  the  position  of  the  child  and  its  general  condition. 

The  fetal  heart  sound  can  usually  be  heard  a  little  after  the  middle 
of  pregnancy,  viz.,  the  latter  part  of  the  fifth  or  the  beginning  of  the 
sixth  month.  The  time  at  which  it  can  be  heard  depends  considerably 
upon  the  skill  and  experience  of  the  listener,  the  position  of  the  fetus, 
the  thickness  of  the  abdominal  wall,  and  the  amount  of  liquor  amnii 
present.  It  is  usually  a  double  sound  resembling  that  heard  at  the  apex 
of  an  adult  heart  but  much  more  rapid.  It  is  often  compared  to  the 
ticking  of  a  watch  under  a  pillow.  Its  rate  varies  from  120  to  IGO  per 
minute.  During  the  beginning  of  a  uterine  contraction  the  rate  is  usually 
increased  only  to  decrease  below  the  normal  at  the  height  of  the  contrac- 
tion, then  to  normally  resiune  its  rate.  Tlie  rate  of  the  fetal  heart  beat 
was  for  a  time  considered  a  guide  to  the  diagnosis  of  the  sex  of  the  child. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY  145 

a  slow  fetal  heart  indicating  a  boy,  and  a  rapid  fetal  heart  a  girl.  Further 
experience  and  observation  have,  however,  proved  this  fallacious  as  a 
guide  (see  page  183). 

DIFFERENTIAL   DIAGNOSIS    OF   PREGNANCY. 

One  of  the  most  difficult  problems  presented  to  the  obstetrician  or  the 
gynecologist  is  the  diagnosis  of  early  pregnancy.  So  difficult  is  it  in  many 
cases,  and  so  embarrassing  is  an  error  in  the  matter,  alike  to  the  patient 
and  the  medical  attendant,  that  it  is  never  advisable  until  the  third 
month  of  pregnancy  to  diagnose  that  condition  without  reservation. 

Pregnancy  may  be  to  the  patient  the  greatest  delight  and  the  object 
long  sought,  or  on  the  other  hand  it  may  be  the  condition  most  dreaded. 
It  may  be  the  condition  of  greatest  importance  to  her  socially,  morally, 
legally,  and  financially,  hence  her  interest  in  an  accurate  diagnosis. 
To  the  obstetrician  an  error  in  the  diagnosis  of  pregnancy  may  be  the 
cause  of  ridicule  and  injured  reputation  which  will  require  months  or 
years  to  overcome.  Hence  the  need  of  caution.  The  reasons  for  error 
in  the  diagnosis  of  pregnancy  are  numerous.  One  of  the  chief  signs  of 
pregnancy  is  an  enlargement  of  the  uterus.  Yet  many  enlargements 
of  the  uterus  exist  without  pregnancy  and  our  problem  is  their  differ- 
entiation. 

The  uteri  of  different  women  may  vary  in  size.  Some  women  normally 
have  a  larger  uterus  than  others,  and  unless  the  usual  size  of  the  uterus 
of  the  individual  case  is  previously  known  to  the  examiner,  her  normal 
uterus  may  be  considered  enlarged  and  pregnancy  suspected. 

Again,  a  uterus  may  be  enlarged  from  a  subinvolution  or  a  metritis, 
and  such  enlargement  gives  rise  to  the  suspicion  of  pregnancy.  Some 
of  the  usual  differential  features  are  as  follows : 

Pregnancy vs. Subinvolution  or  Metritis 

Amenorrhea.  MenorrhaKia. 

Body  of  the  uterus  soft.  Body  of  the  uterus  firmer. 

Body  of  the  uterus  jug-shaped.  Body  of  the  uterus  less  jug-shaped. 

Perhaps  cer\dx  soft  in  each. 

One  of  the  commonest  enlargements  of  the  uterus  presenting  difficulty 
in  diagnosis  from  pregnancy  is  that  due  to  the  presence  of  one  or  more 
fibromyomata,  especially  one  of  the  interstitial  or  submucous  variety  in 
which  the  outline  of  the  uterus  is  nearly  symmetrical. 

The  following  differential  features  should  be  borne  in  mind: 

Pregnancy vs. Fibromyoma. 

Uterus  shows  rapid  growth.  Growth  slow. 

Shape  usually  symmetrical.  Shape  usually  irregular  and  nodular. 

Amenorrhea.  Menorrhagia. 

Cervix  soft.  Cervix  firm. 

Nausea  perhaps  present.  Nausea  absent. 

Positive  symptoms  of  pregnancy.      (Fetal         Positive    symptoms   of   pregnancy   absent. 

heart;    fetal    movements;  ballottement 

perhaps  present). 

Breast  signs  perhaps  present.  Breast  signs  absent. 

10 


^-^ 


a*-- 


146  THE  SYMPTOMS  AND  SIGNS  OF  PREGNANCY 

The  unusual  difficulties  in  diagnosing  these  conditions  may  well  be 
mentioned  here.  A  fibromyoma  will  occasionally  undergo  a  degenerative 
change  from  disturbed  circulation,  will  soften  at  the  centre,  and  will 
grow  almost  if  not  quite  as  rapidly  as  a  pregnancy,  thus  resembling 
pregnancy  in  softness  and  growth,  but,  unless  near  the  menopause,  not 
giving  the  amenorrhea  usually  associated  with  pregnancy. 

The  impregnated  ovum  lodging  in  one  horn  of  the  uterus  occasionally 
gives  an  asymmetrical  shape  to  the  organ  which  may  be  mistaken  for 
a  myoma.  This,  however,  does  not  disturb  other  signs  and  symptoms 
usually  presented  by  pregnancy. 

It  would  hardly  be  expected  that  an  ovarian  tumor  should  present 
marked  difficulties  in  diagnosis  from  pregnancy,  yet  the  following  case 
seen  in  consultation  by  the  author  will  indicate  such  a  possibility.  A 
young  unmarried  girl,  eighteen  years  of  age,  an  inmate  of  an  institution 
for  the  feeble-minded,  was  supposed  to  be  pregnant  and  an  orderly  of 
the  institution  was  suspected  of  the  crime.  The  girl's  abdomen  was 
about  the  size  of  a  pregnancy  at  term.  The  girl  had  never  menstruated 
and  her  continued  amenorrhea  was  assigned  to  her  pregnancy.  To  further 
strengthen  the  diagnosis  of  supposed  pregnancy,  fluid  could  be  expressed 
from  her  nipples.  Careful  examination,  however,  revealed  an  intact 
hymen;  a  small  uterus  separate  from  the  tumor  which  proved  to  be  an 
ovarian  cyst.  The  anemia  and  poor  nutrition  of  the  girl  explained  the 
amenorrhea  and  the  ovarian  stimulation  resulting  from  the  presence  of 
the  tumor  explained  the  breast  secretion. 

The  differential  features  by  which  it  is  usually  possible  to  distinguish 
pregnancy  from  an  ovarian  cyst  are  given  in  the  following  table: 

PhEGNANCY vs. OVARIAX   Ctst. 

Amenorrhea.  Normal  menstruation. 

Tumor  more  central.  Tumor  more  lateral. 

Tumor  less  elastic,  perhaps  fetal  parts  felt.  Tumor  more  elastic,  no  fetal  parts  felt. 

Breast  signs  present.  Breast  signs  absent. 

Positive  sjonptoms   of   pregnancy   perhaps  Positive  symptoms  absent, 
present. 

If  both  pregnancy  and  an  ovarian  cyst  exist  the  signs  of  each  are  present 
and  the  diagnosis  may  be  difficult. 

Spurious  Pregnancy  or  Pseudocyesis. — ^At  first  thought  it  seems 
strange  that  a  woman  should  become  so  convinced  that  she  is  pregnant 
as  to  carry  this  conviction  through  nine  months  or  more  of  supposed 
pregnancy  and  anxiously  await  the  onset  of  labor.  However,  the  three 
signs  which  the  laity  recognize  as  evidences  of  pregnancy  are  the  cessa- 
tion of  menstruation,  an  increasing  size  of  the  abdomen,  and  fetal 
movements. 

These  three  signs  may  'occasionally  be  apparently  present  and  the 
woman  suppose  herself  pregnant  when  in  reality  this  is  not  her  condition. 
The  explanation  is  as  follows: 

In  the  first  place  this  spurious  pregnancy  is  most  apt  to  occur  near  the 
menopause  when  amenorrhea  is  the  rule.  Furthermore,  at  this  period 
of  a  woman's  life  an  increase  of  abdominal  fat  and  intestinal  fermentation 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY  147 

is  common.  The  two  signs  of  pregnancy,  amenorrhea  and  an  enlarged 
abdomen  are  thus  furnished.  The  third,  or  fetal  movement,  is  now  sup- 
plied by  the  motion  of  the  intestinal  gas  supplemented  by  a  vivid  imagina- 
tion on  the  part  of  the  woman.  Not  infrequently  these  cases  of  pseudo- 
cyesis  occur  in  women  who  for  years  have  longed  for  pregnancy  and  who 
have  been  anxiously  watching  for  the  first  indication.  Is  it  any  wonder 
then  that  they  should  be  deceived?  The  embarrassment,  alike  to  the 
attending  physician  and  the  patient,  resulting  from  an  undiagnosed 
pseudocyesis,  is  well  illustrated  by  the  following  case  seen  by  the  author 
in  consultation.  The  patient,  a  woman  of  wealth,  and  her  physician  had 
supposed  her  labor  past  due  and  the  consultation  was  held  to  determine 
why  labor  did  not  ensue.  On  being  conducted  to  the  patient's  chamber 
the  author  was  obliged  to  pass  through  a  room  prepared  as  a  nursery 
for  the  expected  child.  A  more  complete  private  nm-sery  it  would  be 
difficult  to  find  and  this  was  supplemented  with  all  sorts  of  beautiful 
articles  of  a  baby's  wardrobe,  the  gifts  of  numerous  friends,  all  interested 
in  the  arrival  of  the  first,  much-longed-for  child  in  this  family.  On 
reaching  the  bedside  of  the  patient  and  after  careful  examination  it 
was  his  painful  duty  to  inform  the  physician  that  his  patient  was  not 
pregnant. 

The  difficulty  in  these  cases  usually  lies  in  the  fact  that  the  attending 
obstetrician  has  taken  the  statements  of  the  patient  at  their  face  value 
without  making  a  careful  examination  which  would  usually  disclose  a 
small,  firm  uterus  and  would  enable  the  examiner  to  exclude  pregnancy. 
The  usual  differential  features  are  as  follows: 

Pregnancy vs. Pseud  octesis. 

Cervix  soft.  Cervix  firm. 

Uterine  body  enlarged.  Uterine  body  not  enlarged. 

Positive  signs  of  pregnancy  perhaps  present.  Positive  signs  of  pregnancy  absent. 

Tumor  does  not  disappear  on  pressure.  Tumor  disappears  on  steady  pressure,    or 

under  anesthesia. 

As  an  illustration  of  the  completeness  of  the  patient's  subjective  decep- 
tion in  the  condition  of  pseudocyesis,  the  author  remembers  distinctly 
a  case  brought  to  his  hospital  service,  who  after  nine  months  of  supposed 
pregnancy  had  eaten  an  indigestible  meal,  was  taken  with  severe  intes- 
tinal colic,  supposed  herself  in  labor  at  about  the  right  time  and  was 
brought  to  the  hospital  in  the  ambulance.  The  difficulty  in  persuading 
this  woman  that  she  was  not  pregnant  was  so  great  that  it  made  a  lasting 
impression. 

Ascites. — The  differentiation  between  advanced  pregnancy  and  ascites 
is  usually  easy  on  careful  examination.  The  usual  differential  features 
are  as  follows : 

Pregnancy vs. Ascites. 

Patient  on  back.     Percussion  note  dull  in         Resonance  in  front. 

front. 
Fluctuation  not  distinct.  Fluctuation  distinct. 

Amenorrhea.  Regular  menstruation. 

Cervix  soft.  Cer\ax  firm. 

Uterine  body  enlarged.  ,  Uterine  body  not  enlarged. 

Positive  symptoms  of  pregnancy  present.  Positive  sj-mptoms  of  pregnancy  absent. 


148 


THE  SYMPTOMS  AND  SIGNS  OF  PREGNANCY 


Is  the  Patient  a  Primigravida  or  a  Multigravida? — The  answer  to  this 
question  sometimes  has  considerable  importance  and  hence  the  usual 
differential  features  are  given. 


Primigravida i 

Abdominal  wall  firm  and  tense. 

Fetal  parts  less  distinct. 

Striie  appear  late,  and  are  reddish  bruwii 
in  color. 

Breasts  full  and  firm,  perhaps  with  fresh 
striae. 

Labia  in  apposition. 

Vagina  narrow.     Rugaj  distinct. 

Hymen  fissured  but  different  portions  pre- 
served. 

Os  externum  closed  until  late  in  pregnancy. 

Lacerations  of  cervix  and  perineum  absent. 


-Multigravida. 


Abdominal  wall  lax,  often  wrinkled. 

Fetal  parts  more  distinct. 

Besides  fresh  striae  as  in  a  primigravida,  old 

white,  silvery  striae  exist  from  the  start. 
Breasts    flabby,    pendulous,    perhaps    with 

both  fresh  and  old  striae. 
Vulva  gaping,  showing  vagina  of  violet  hue. 
Vagina  more  capacious;  rugae  less  distinct. 
Carunculae  myrtiformes  alone  remain. 

Os  externum  patulous. 

Lacerations  of  cervix  and  perineum  perhaps 
present. 


The  absence  of  the  above  signs  described  as  belonging  to  a  multigravida 
does  not  absolutely  exclude  a  premature  labor  or  even,  in  rare  cases,  the 
delivery  of  a  small  fetus  at  term. 


CHAPTER  V. 
THE  MANAGEMENT  OF  NORMAL  PREGNANCY. 

Until  recent  times  pregnancy  was  considered  a  physiological  process 
which  should  be  followed  by  a  normal  completion,  and  there  was 
thought  to  be  no  necessity  for  the  pregnant  woman  to  place  herself  in 
the  care  of  the  obstetrician  until  a  short  time  before  her  expected 
confinement. 

Fortunately  for  the  patient  and  her  unborn  child  these  views  are  now 
obsolete,  and  the  laity  have  become  educated  to  the  fact  that  while  normal 
pregnancy  is  physiological,  the  possibility  of  pathological  conditions 
intruding  themselves  insidiously  is  so  great  that  the  pregnant  patient 
can  only  safeguard  her  pregnancy  by  placing  herself  in  the  hands  of  her 
obstetrician  almost  immediately  after  her  pregnant  state  is  suspected. 

If  the  pregnancy  is  her  first  she  is  probably  ignorant  as  to  the  proper 
mode  of  life  during  this  condition,  and  it  is  a  comfort  to  her  as  well  as 
adding  greatly  to  her  safety  to  have  the  obstetrician  carefully  outline 
and  supervise  her  conduct  during  the  entire  period  of  gestation. 

By  many  it  is  thought  unnecessary  to  make  a  physical  examination 
during  the  early  months  of  pregnancy,  but  with  this  the  author  does  not 
agree,  and  in  his  mind  there  are  many  reasons  why  the  obstetrician  should 
make  a  thorough  physical  examination,  including  both  the  vaginal  and 
the  bimanual,  as  soon  as  the  supposed  pregnant  patient  places  herself 
in  his  care.     Among  these  reasons  may  be  mentioned  the  following: 

The  possibility  of  error  in  the  diagnosis  of  pregnancy  and  the  embar- 
rassment alike  to  the  patient  and  obstetrician  resulting  from  this  error 
is  so  great,  that  the  obstetrician  should  not  commit  himself  to  this  diag- 
nosis until  he  has  absolutely  satisfied  himself  of  the  existence  of  pregnancy 
by  a  careful  physical  examination.  Furthermore,  the  frequency  of  the 
existence  of  a  retroversion  of  the  uterus,  which  if  uncorrected  may  result 
in  an  early  miscarriage,  furnishes  a  very  strong  argument  for  determining 
early  in  pregnancy  the  condition  and  position  of  the  pelvic  organs. 

Although,  save  in  the  case  of  manifestly  markedly  deformed  pelves, 
it  is  seldom  necessary  to  perform  pelvimetry  before  the  seventh  month 
of  pregnancy,  it  is  the  author's  practise  to  carefully  measure  the  pelvis 
of  the  patient  as  soon  as  she  places  herself  in  his  care,  feeling  that  with 
this  detailed  knowledge  of  her  condition  he  is  better  able  to  advise  her 
during  her  pregnancy. 

In  giving  advice  to  a  pregnant  patient  it  is  always  wise  to  consider 
her  ignorant  of  the  proper  mode  of  life  in  this  condition,  and  give  her 

(149) 


150  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

minute  directions  as  to  diet,  dress,  exercise,  marital  relations,  regulation 
of  the  bowels,  etc. 

Diet. — In  the  early  months  of  pregnancy,  if  the  urine  is  normal  the 
patient  can  usually  be  allowed  to  select  her  diet  according  to  her  taste, 
which  will  often  vary  greatly  from  that  in  the  non-pregnant  condition. 

If  the  patient  suffers  with  nausea  there  are  two  rules  of  feeding  which 
will  often  add  greatly  to  her  comfort. 

1.  Have  her  take  before  rising  in  the  morning  some  easily  digested 
food,  as  a  cracker  or  two,  a  glass  of  milk  or  some  toast  and  a  cup  of  coffee 
and  then  rest  awhile  before  performing  her  toilet  and  dressing. 

2.  As  the  feelings  of  the  pregnant  patient  resemble  somewhat  the 
feelings  when  slightly  seasick  on  shipboard,  the  author  is  in  the  habit 
of  advising  his  patients  to  follow  the  custom  pursued  at  sea  of  eating 
little  and  often.  The  patient  usually  feels  worse  when  her  stomach  is 
empty.  By  the  fourth  month,  if  not  earlier,  the  patient's  appetite  usually 
returns  and  she  should  be  allowed  a  generous  plain  diet  including  meats, 
vegetables,  and  fruits.  During  the  last  month,  in  order  to  lessen  the  work 
of  liver  and  kidneys,  it  is  my  custom  to  limit  the  ingestion  of  red  meat 
to  three  times  a  week.  As  advocated  by  Prochownick  and  others,  if  the 
patient  has  pre\ioiisly  borne  very  large  children  or  the  pelvis  is  slightly 
contracted,  the  size  of  the  child  may  be  reduced  without  injury,  by  having 
the  patient  during  the  last  few  months  of  pregnancy  take  less  than  the 
ordinary  amount  of  carboh>'drates,  less  fluid  with  her  meals  and  rise  from 
the  table  with  appetite  not  entirely  satisfied.  In  this  way  the  labors  in 
some  women  are  rendered  easier. 

Drink. — To  favor  elimination  so  important  during  pregnancy,  drinking 
freely  of  water  is  very  desirable  and  this  is  more  easily  regulated  by 
giving  the  patient  directions  as  to  when  and  how  much  she  shall  take. 
An  excellent  plan  is  to  tell  her  to  take  six  glasses  of  water  per  day:  one 
early  in  the  morning,  two  in  the  middle  of  the  forenoon,  two  in  the  middle 
of  the  afternoon,  and  one  before  retiring. 

The  ordinary  articles  of  fluid  diet,  milk,  chocolate,  tea  and  coffee  in 
moderation  are  allowable  in  pregnancy  but  alcoholic  beverages  should  be 
avoided  to  save  irritation  of  the  already  overtaxed  liver  and  kidneys. 

Dress. — The  clothing  of  the  pregnant  woman  should  in  general  be 
arranged  with  a  view  to  her  comfort  rather  than  to  suit  the  taste  of  the 
Paris  dressmaker.  There  is  no  objection  to  the  use  of  corsets,  if  the\'  fit 
properly  and  can  be  easily  adjusted  to  the  increasing  demand  for  room. 
The  object  desired  is  support,  not  compression.  In  the  primigravida 
where  the  abdominal  wall  is  tense,  additional  support  will  seldom  be 
needed,  and  all  that  is  required  is  the  use  of  gradually  loosened  corsets 
of  the  ordinary  type  in  early  pregnancy  and  a  maternity  corset  with  few 
"bones"  and  elastic  sides,  or  a  corset  waist,  in  later  pregnancy.  In 
women  with  well-developed  breasts,  a  certain  amount  of  breast  support 
is  necessary  for  their  comfort  and  if  as  at  present  the  prevailing  style 
of  corset  is  too  low  for  this,  it  is  well  to  have  them  wear  one  of  the  numerous 
styles  of  breast  supporter,  usually  made  of  plaited  ribbons  or  bands. 


EXERCISE  151 

In  the  case  of  multigravidse  with  very  lax  abdominal  walls,  and  occa- 
sionally even  in  primigravidse  a  well-fitting  bandage  which  preserves 
the  proper  uterine  axis  not  only  adds  to  the  comfort  of  the  woman  but 
favors  engagement  of  the  fetal  head  at  the  proper  time.  As  far  as  possible 
the  weight  of  the  clothing  should  be  supported  from  the  shoulders  rather 
than  the  waist. 

Stockings  should  be  held  by  side  supporters  rather  than  by  circular 
garters. 

If  the  patient  suffers  with  varicose  veins  of  the  lower  extremities 
elastic  stockings  may  be  needed  for  support  and  comfort. 

Exercise. — Except  in  cases  where  the  woman  has  suffered  from  previous 
early  miscarriages  it  is  advisable  to  have  her  take  regular,  moderate 
exercise.  In  the  early  months  if  she  suffers  much  from  nausea  this  may 
be  almost  impossible  for  her  and  should  not  be  insisted  on.  She  needs 
and  will  be  benefited  by  fresh  air,  but  this  can  be  obtained  by  spending 
much  time  on  the  porch,  or  by  a  carriage  or  slow  motor  ride.  Just  as 
soon,  however,  as  the  nausea  ceases,  or  markedly  lessens  and  the  feeling 
of  well-being  returns  she  should  be  encouraged  to  take  short  walks  which 
are  gradually  increased  until  she  walks  regularly  from  one  to  two  miles 
a  day.  During  early  pregnancy  it  is  well  to  lessen  the  exercise  each  month 
on  the  days  which  would  have  been  her  menstrual  period. 

As  to  the  variety  of  exercise,  walking  is  the  best.  It  is  well  to  advise 
against  lawn  tennis  and  horseback  riding.  It  is  well  known  that  some 
women  can  indulge  in  almost  any  form  of  exercise  without  interrupting 
pregnancy  and  recenth'  one  of  my  patients  who  was  fond  of  exercise  and 
of  horses,  not  knowing  she  was  pregnant  had  been  enjoying  the  sport  of 
"breaking"  some  bucking  horses  up  to  the  time  when  she  came  to  me  to 
find  out  why  she  did  not  menstruate.  She  was  then  three  months  pregnant 
and  went  to  term  with  a  perfectly  normal  pregnancy  and  puerperium. 
However,  it  seems  to  require  in  others  but  a  slight  jolt  or  mental  start 
to  interrupt  the  pregnancy,  and  for  this  reason  it  is  well  to  advise  against 
horseback  riding  in  this  condition. 

At  the  present  day  the  question  is  constantly  asked  if  it  is  safe  for  the 
pregnant  woman  to  motor.  In  the  experience  of  the  author  this  depends 
entirely  upon  the  condition  of  the  roads  and  the  carefulness  of  the 
chauffeur.  If  the  roads  are  smooth  and  the  car  is  run  slowly,  motoring 
does  no  harm  and  furnishes  diversion  and  fresh  air,  both  of  which  are 
very  desirable. 

The  exact  amount  of  exercise  must  vary  with  the  endurance  of  each 
patient  rather  than  be  fixed  by  any  rule.  The  object  sought  is  exercise 
without  overfatigue.  When  the  patient  is  unable  to  take  a  sufficient 
amount  of  exercise,  general  massage,  avoiding  the  abdomen,  is  of 
value. 

Traveling. — The  physician  is  often  asked  as  to  the  advisability  of  a 
trip  abroad  or  a  long  journey  during  pregnancy.  It  is  wise  as  a  rule  to 
advise  against  this  for  several  reasons:  The  frequency  with  which  inter- 
ruption of  pregnancy  is  caused  by  the  jolting  of  railroad  trains  on  the  one 


152  THE  MANAGE MEXT  OF  NORMAL   PREGNANCY 

hand  and  the  straining  of  seasickness  on  the  other  is  too  great  to  be 
neglected.  Furthermore,  the  absence  from  skilled  supervision  of  the 
patient's  urine  and  avenues  of  elimination  coupled  frequently  with 
inadequate  facilities  for  -<lealing  with  com])licati()ns  of  all  kinds  when 
far  from  home  makes  home  or  its  neighborhood  the  best  place  for  a 
woman  during  her  pregnancy. 

Bathing. — The  proper  care  of  the  skin  during  pregnancy  is  of  marked 
importance  and  the  continuance  of  the  daily  bath  is  not  only  allowable 
but  desirable.  The  temperature  of  the  bath  may  be  that  to  which  the 
patient  is  accustomed,  but  sudden  shocks  of  ^■ery  cold  water  and  bathing 
in  very  hot  water  are  to  be  avoided.  Sea  bathing  in  relatively  still  water 
is  beneficial,  but  bathing  in  heavy  surf  should  not  be  allowed. 

Fresh  Air. — So  long  as  it  is  remembered  that  the  patient  is  breathing 
for  two  it  is  seen  how  important  it  is  that  she  should  have  fresh  air  and 
plenty  of  it.  The  ease  with  which  a  pregnant  patient  faints  in  a  room 
which  is  overcrowded  and  where  the  air  is  bad  shows  nature's  demand 
for  fresh  air  in  abundance.  For  this  reason  overcrowded  and  over- 
heated rooms  with  poor  ventilation  should  be  regarded  as  unfit  for  a 
woman  in  this  condition. 

Marital  Relations. — The  question  of  marital  relations  during  pregnancy 
is  an  important  one.  It  is  well  established  that  the  frequent  sexual 
intercourse  of  newly  married  life  is  a  frequent  cause  of  miscarriage. 

On  the  other  hand  it  is  too  well  known  that  the  long  abstinence  of  some 
husbands  during  the  pregnancy  of  their  wives  has  caused  them  to  yield 
to  temptation  away  from  home,  with  dire  results  to  the  future  happiness 
and  perhaps  health  of  themselves  and  their  wives.  If  there  is  no  history 
of  previous  miscarriages,  pregnant  patients  may  safely  be  told  that  they 
may  indulge  in  sexual  intercourse  one  or  twice  a  week  up  to  the  eight 
month,  except  during  the  week  each  month  which  corresponds  to  their 
menstrual  period.  During  these  times,  and  especially  during  the  last 
month  of  pregnancy,  intercourse  should  be  interdicted.  The  danger 
of  puerperal  infection  from  intercourse  during  the  last  month  of  preg- 
nancy makes  such  interdiction  extremely  important.  As  will  be  discussed 
under  the  prophylactic  treatment  of  miscarriages,  if  the  patient  gives 
a  history  of  repeated  miscarriages  all  intercourse  during  pregnancy  must 
be  avoided. 

As  to  the  sexual  desire  of  women  during  pregnancy,  while,  as  a  rule, 
it  is  normal  or  decreased,  in  a  few,  apparently  from  the  greater  pelvic 
congestion,  it  is  increased. 

Regulation  of  the  Bowels. — Great  as  is  the  tendency  to  constipation 
in  modern  women,  tliis  tendency  becomes  increased  in  pregnancy  from 
the  pressure  of  the  enlarging  uterus  interfering  with  intestinal  peristalsis. 
It  is  very  desirable  (1)  that  the  patient  should  have  a  regular  movement 
each  day,  (2)  that  this  movement  should  be  brought  about  with  as  few 
drugs  as  possible.  In  some  women  the  drinking  freely  of  water  as  already 
advised,  and  eating  of  fruits  and  green  vegetables  will  accomplish  the 
desired  result,  especially  if  at  the  same  time  the  bread  eaten  is  very 


CARE  OF  THE  VULVA  AND  VAGINA  153 

coarse.  In  other  women  further  help  is  needed.  For  this  two  methods 
are  at  our  command.  (1)  Enemata  or  suppositories,  (2)  mild  laxatives. 
It  is  well  not  to  use  continuously  either  the  same  method  or  the  same 
article  in  the  method.  An  enema  of  soapsuds  may  be  used  at  times 
alternating  with  a  glycerin  or  gluten  suppository.  Of  laxatives,  the  two 
which  have  given  me  the  greatest  satisfaction  are  (1)  the  fluidextract 
of  cascara  in  tablet  form  (aa  TIlv)  of  which  from  one  to  three  may  be  taken 
at  bedtime,  and  (2)  a  tablet  composed  of  aloin,  belladonna,  strychnin 
and  cascarin  to  be  taken  at  bedtime.  It  is  often  of  value  to  administer 
a  small  dose  of  calomel  at  intervals  during  pregnancy.  The  use  of  mineral 
waters  as  laxatives  during  pregnancy,  while  perhaps  beneficial  for  a  time, 
rather  tend  to  constipation  later. 

Mental  Condition. — During  pregnancy  the  mental  condition  of  the 
woman  is  usually  that  of  high  tension  and  unstable  equilibrium.  There 
are  numerous  causes  for  this:  she  may  have  found  herself  pregnant 
unexpectedly,  perhaps  unwillingly;  her  plans  for  the  year  or  two  to  come 
may  have  to  be  entirely  rearranged;  she  may  feel  like  secluding  herself 
from  her  friends  and  abstaining  from  occupations  she  enjoys;  she  may 
feel  wretchedly  from  the  nausea  which,  although  made  light  of  by  her 
friends,  is  disagreeable  enough  for  her;  she  may  dread  the  ordeal  of  her 
labor,  and  last,  but  by  no  means  least,  she  may  be  suffering  from  a  toxemia, 
the  result  of  insufiicient  oxidation  and  elimination  which  shows  itself 
chiefly  in  the  nervous  system. 

The  mental  condition  of  some  patients  is  well  illustrated  by  the  experi- 
ence of  one  of  my  old  teachers  who  said  that  he  had  a  patient  "whose 
disposition  when  not  pregnant  seemed  to  him  angelic,  but  who  acted 
when  pregnant  as  though  possessed  of  the  devil."  Certain  it  is  that  there 
is  often  a  tendency  to  nervous  irritation,  and  the  surroundings  of  the 
patient  should  be  made  as  cheerful  and  pleasing  as  possible,  free  from  all 
unnecessary  causes  of  fret  and  worry.  It  is  well  to  explain  this  condition 
to  the  husband  and  to  tell  him  that  his  share  will  consist  in  making 
allowances  for  any  little  irritability  on  the  part  of  his  wife  and  in  doing 
all  he  can  to  add  to  her  comfort,  her  diversion,  and  her  cheer. 

Breasts. — While  speaking  of  the  clothing  of  the  pregnant  patient, 
attention  was  called  to  the  fact  that  when  the  breasts  were  large  and  heavy 
much  comfort  could  be  given  by  proper  support.  In  addition  to  this  much 
discomfort  can  be  avoided  by  proper  care  of  the  nipples  during  pregnancy, 
especially  during  the  latter  half.  Aside  from  the  cleansing  by  the  daily 
bath,  the  nipples  should  be  kept  free  from  the  crusts  which  tend  to  form 
upon  them  as  soon  as  secretion  begins  to  exude.  Many  lotions  have  been 
used  for  this  purpose.  The  one  which  the  author  usually  employs  is 
composed  of  borax,  §  ss,  and  50  per  cent,  alcohol,  §  viij,  with  the  direction 
to  bathe  the  nipples  with  it  night  and  morning.  If  the  nipples  are 
retracted  the  patient  is  told  during  the  last  third  of  pregnancy  to  draw 
them  out  gently  with  the  fingers  each  time  she  uses  the  lotion. 

Care  of  the  Vulva  and  Vagina. — Although  more  or  less  leucorrheal 
discharge  is  quite  common  in  pregnancy,  especially  in  multigravidse,  it  is, 


154  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

as  a  rule,  unwise  to  use  vaginal  douches  unless  there  exists  some  special 
indiaition  in  the  shape  of  disease.  It  has  been  shown  by  Kronig,  Menge, 
Williams  and  others  that  the  vagina  of  the  normal  pregnant  woman 
does  not  contain  pathogenic  organisms  and,  save  for  the  possibility  of 
gonorrheal  infection,  may  be  regarded  as  normally  free  from  the  source 
of  puerperal  infection. 

Kronig  also  showed  that  the  vagina  possessed  certain  bactericidal 
powers  which  were  weakened  by  antiseptic  douches.  Unless,  therefore, 
the  woman  is  suffering  from  a  gonorrheal  infection  which  indicates  treat- 
ment, both  for  her  sake  and  that  of  her  baby,  vaginal  douches  had,  as  a 
rule,  better  be  omitted.  If  the  leucorrhea  produces  irritation  of  the  vulva, 
bathing  the  vulva  with  borax  and  water  (5j~0j)  will  usually  give  relief. 
In  addition  to  this,  bathing  with  milk  of  magnesia  often  gives  marked 
comfort. 

It  is  especially  important  that  all  douching  should  be  discontinued 
during  the  last  month  of  pregnancy  so  that  the  woman  may  enter  upon 
her  labor  with  vagina  untouched  by  douche,  and,  as  already  indicated, 
by  coitus  for  at  least  a  month. 

Urine. — There  is  no  secretion  which  furnishes  so  good  a  criterion  of 
the  condition  of  the  pregnant  woman  as  the  urine,  although  it  is  freely 
admitted  that  instances  not  infrequenctly  occur  in  which  the  woman  is 
in  grave  danger  without  the  ordinary  clinical  examination  of  the  urine 
detecting  it,  still  it  is  the  best  single  criterion  which  we  possess  and  if 
it  is  examined  carefully  and  frequently  it  is  rare  that  danger  signals 
escape.  The  knowledge  of  the  importance  of  frequent  urinary  examina- 
tions has  now  become  so  widespread  among  the  laity  that  the  physician 
attending  a  case  of  obstetrics  without  these  precautions  is  justly  held 
culpable.  The  urine  should  be  examined  every  two  weeks  from  early 
pregnancy  even  if  absolutely  normal,  and  in  order  to  prevent  neglect  on 
the  part  of  the  patient  it  is  wise  to  give  the  date  on  which  the  specimen 
is  to  be  sent.  It  is  my  custom  to  tell  patients  to  send  four  ounces  of  the 
morning  urine,  to  insure  its  freshness  when  it  reaches  the  office.  This 
ordinary  examination  of  the  urine  should  include  not  only  the  tests  for 
albumin  and  sugar,  the  reaction  and  specific  gravity,  but  also  the  micro- 
scopic examination  for  casts  and  other  abnormal  contents.  In  addition 
to  these  it  is  also  desirable  to  ascertain  the  condition  of  proteid  metab- 
olism by  testing  for  acetone  and  diacetic  acid. 

The  above  remarks  apply  where  the  urine  and  course  of  pregnancy 
seem  normal.  If  albumin  or  other  abnormalities  are  found  the  urine 
should  be  examined  much  more  frequently,  even  perhaps  every  day  for 
a  time,  and  during  the  last  month  of  pregnancy  it  is  wise  to  have  a  speci- 
men sent  every  week  even  if  everything  is  normal. 

A  convenient  blank  for  urine  analysis  is  the  following: 


OBSERVATION  OF   THE  PATIENT  155 

URINE   ANALYSIS. 

Name 

Report  No 

Date 

Volume  in  twenty-four  hours Oz c.c. 

Color - 

Sediment Reaction 

Specific  gravity 

_Urea Grains  per  ounce  grains,  twenty-four  hours 

Albumin    Amount  grains,  twenty-four  hours 

Sugar Amount  (polariscope)        grains,  twenty-four  hours 

Acetone 

Diacetic  acid    .. 

Indican    

Bile    

Blood  pigments   

MICROSCOPIC  EXAMINATION. 

Casts  Leukocytes  

Mucus Epithelia *  — 

Amorphous  deposits    Bacteria 

Crystals Other  elements 

Red  blood  cells 

Blood-pressure. — The  importance  of  carefully  taking  the  blood- 
pressure  of  a  patient  at  short  intervals  during  her  pregnancy  has  now 
become  well  established.  It  is  one  of  the  most  valuable  criteria  of  the 
condition  of  her  elimination  and  the  presence  or  absence  of  a  toxemia. 
This  will  be  considered  later  when  studying  toxemia,  but  attention 
should  now  be  directed  to  its  importance  as  a  guide  to  the  condition 
of  the  woman  during  her  pregnancy  and  the  need  of  noting  any  departure 
from  the  normal  which  usually  varies  between  100  and  130. 

With  the  numerous  portable  sphygmomanometers  now  on  the  market 
it  is  an  easy  task  to  follow  the  blood-pressure. 

Observation  of  the  Patient. — The  patient  should  be  seen  frequently, 
for  it  is  only  by  frequent  observation  of  the  patient  together  with  frequent 
examinations  of  the  urine  that  it  is  possible  to  surround  the  pregnant 


156  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

wuiiian  with  the  safeguards  to  which  she  is  entitled.  ]\Iuch  can  be  told 
by  the  appearance  of  the  patient;  her  color  and  facial  expression;  the 
presence  or  absence  of  edema;  the  tension  of  her  ])ulse  and  by  certain 
symptoms  which  can  be  elicited  by  (questions  but  which  would  not  have 
been  reported  otherwise.  It  is  a  good  plan  to  have  patients  send  speci- 
mens every  two  weeks  and  to  come  with  the  specimen  at  least  every 
other  time  even  if  feeling  well.  This  enables  the  physician  to  see  them 
at  least  every  four  weeks.  In  addition  it  is  wise  to  give  them  a  printed 
card  like  the  following,  calling  their  attention  to  certain  symptoms 
which  should  be  reported  if  present: 

Directions  during  Pregnancy. 

Be  careful  to  send  or  bring  a  specimen  of  the  urine  in  a  clean  bottle  holding 
from  -i  to  6  ounces  every  two  weeks.  Have  your  name  and  address  upon  the  bottle. 
Even  if  feehng  perfectly  well,  come  to  the  office  mth  at  lea.st  eveiy  other  specimen. 

Drink,  if  possible,  six  glasses  of  water  each  day  between  meals,  i.  e.,  one  the 
first  thing  in  the  morning;  two  during  the  forenoon;  two  during  the  afternoon 
and  one  just  before  retiring. 

Be  careful  to  have  the  bowels  move  regularly  each  day  and  report  any  iualnlity 
in  this  direction. 

For  exercise,  walking  is  the  best.  Walk  from  one  to  two  miles  each  day.  Avoid 
lawn-tennis,  horseback  riding,  and  fast  or  rough  motoring. 

Bathe  the  nipples  night  and  morning  with  the  solution  prescribed. 

Wear  loose  clothing,  capable  of  being  adjusted  to  the  increasing  size  of  the 
abdomen.  There  is  no  objection  to  loose-fitting  corsets.  Do  not  wear  circular 
garters. 

Report  any  unusual  headache;  any  excessive  vomiting  (especially  after  the 
middle  of  pregnancy);  any  marked  swelUng  of  limbs  or  face;  any  disturbance 
of  vision;   any  bleeding  or  escape  of  water;   any  pain  with  regular  recurrences. 

The  Teeth. — It  is  a  common  experience  that  the  teeth  decay  more 
rapidly  during  pregnancy  than  at  other  times.  It  is  therefore  of  impor- 
tance that  they  should  receive  especial  care  at  this  time.  Not  only  are 
the  various  antiseptic  mouth  washes  of  value,  but  often  an  alkali,  such  as 
the  milk  of  magnesia,  will  prove  beneficial.  The  obstetrician  is  often 
asked  if  it  is  safe  to  have  dentistry  done  during  pregnancy.  ]My  experi- 
ence leads  me  to  tell  patients  that  minor  work  like  the  filling  of  small 
cavities  may  safely  be  done,  but  that  extraction  of  teeth  and  other  major 
work  had  better  be  postponed,  if  possible. 

Patient's  History  and  Examination. — The  obstetrician  who  assumes 
the  responsibility  of  the  care  of  a  woman  during  her  pregnancy  and  puer- 
perium  should  acquaint  himself  with  all  facts  in  her  previous  history 
which  have  a  bearing  upon  the  present  pregnancy  and  confinement. 
At  the  Sloane  Hospital  the  history  blank  ('pages  158  to  163)  has  been 
found  of  value  and,  although  it  is  more  complete  than  will  probably  be 
used  by  the  busy  practising  obstetrician,  from  it  can  easily  be  abstracted 
a  brief  working  history  plan. 

Duration  of  Pregnancy. — A  great  deal  of  annoyance  and  embarrass- 
ment alike  to  obstetrician  and  patient  woidd  be  saved  if  the  exact  dura- 
tion of  pregnancy  in  a  given  case  could  be  determined,  but  this  is  impos- 
sible for  the  reason  that  the  exact  date  of  fertilization  is  tmknown.    Two 


DURATION  OF  PREGNANCY  157 

»  women  may  have  fruitful  intercourse  on  the  same  day  and  yet  the  dates 

of  their  labors  be  widely  separated.  Usually  labor  begins  about  two 
hundred  and  eighty  days  from  the  beginning  of  the  last  menstruation, 
i.  e.,  about  two  hundred  and  seventy-three  days  from  intercourse,  sup- 
posing this  to  occur  right  after  menstruation,  but  many  variations  occur. 
Ahlfeld,^  analyzing  425  cases  in  which  the  date  of  coitus  was  thought 
to  be  kno^Ti,  found  the  duration  of  pregnancy  in  different  cases  to  vary 
from  two  hundred  and  thirty-one  days  to  three  hundred  and  twenty- 
nine  days.  The  cause  of  this  variation  is  largely  dependent  upon  two 
facts : 

1.  The  length  of  time  between  intercourse  and  impregnation  varies  in 
different  people  and  at  different  times.  The  possibility  of  this  is  readily 
seen  when  we  consider  that  spermatozoa  have  been  found  alive  in  the 
uterus  and  Fallopian  tubes  three  weeks  or  more  after  intercourse,  as 
reported  by  Diihrssen,^  and  as  shown  by  Issmer  unimpregnated  ova  may 
remain  alive  for  sixteen  days.^ 

2.  Some  women  habitually  carry  in  utero  their  product  of  conception 
longer  than  others.  This  is  shown  by  the  length,  size  and  weight  of  the 
child  when  born  being  larger  than  normal.  This  increased  size  often 
adds  greatly  to  the  difficulty  of  the  labor  and  will  be  referred  to  again 
as  an  indication  for  the  induction  of  premature  labor  if  the  pregnancy  is 
prolonged  more  than  two  weeks  beyond  term.  This  variation  in  the  dura- 
tion of  pregnancy  is  not  confined  to  the  human  race.  In  the  cow  whose 
period  of  pregnancy  corresponds  closely  to  that  of  woman,  the  duration 
of  pregnancy  is  usually  considered  to  be  two  hundred  and  eighty  days, 
but  variations  were  noted  by  Tessier  ranging  between  two  hundred  and 
forty-one  and  three  hundred  and  eight  days.  In  the  mare  the  average 
duration  of  pregnancy  is  considered  three  hundred  and  sixty-six  days, 
but  in  a  large  series  of  cases  studied  by  Franck-Albrecht-Goring,*  varia- 
tions occurred  between  three  hundred  and  seven  and  four  hundred  and 
twelve  days. 

Date  of  Expected  Confinement. — ^The  method  followed  by  the  author, 
both  in  his  service  at  the  Sloane  Hospital  and  in  his  private  practice,  in 
computing  the  date  of  confinement  is  that  which  bears  the  name  of 
Naegele  who  considers  that  gestation  continues  two  hundred  and  eighty 
days  from  the  first  day  of  the  last  menstrual  period.  This  is  easily  cal- 
culated approximately  by  adding  seven  days  to  the  date  of  beginning 
of  the  last  menstrual  period  and  counting  back  three  months.  Thus, 
if  the  last  menstrual  period  began  on  September  10,  adding  seven  days 
would  make  September  17,  and  counting  back  three  months  would 
give  June  17  as  the  date  of  the  expected  confinement.  This  method 
supposes  the  period  of  gestation  to  continue  nine  calendar  months  from 
the  date  of  intercourse;  that  menstruation  is  over  and  intercourse  indulged 
in,  as  a  rule,  in  seven  days  from  the  beginning  of  the  period. 

1  Beobachtungen  liber  die  dauer  der  Schwangerschaft. 

2  Zeitschr.  f.  Geburts  u.  Frauenkrankh.,  vol.  xvii,  p.  305. 

3  Ueber  die  Zeitdauer  der  menschlichen  Schwangerschaft. 

■i  Die  Trachtigkeitsdauer,  ThierartzHche  Geburtshulfe,  IV  aufl.,  1901,  pp.  153-159. 


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164  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

This  method  of  calculation  will  sometimes  fix  the  exact  day  on  which 
labor  begins  and  usuall\'  will  come  within  a  few  days  of  the  date.  Some- 
times, however,  with  this  rule,  as  with  every  other,  there  will  be  an  error 
of  two  or  even  three  weeks  resulting  either  from  the  fact  that  impreg- 
nation did  not  occur  until  just  before  the  next  period  (which  did  not 
appear),  or  that  gestation  continued  over  time.  It  must  also  be  remem- 
bered that  in  exceptional  cases  impregnation  may  occur  any  time  during 
the  intermenstrual  period.  If  impregnation  followed  a  single  intercourse 
the  date  of  which  is  known,  the  usual  method  of  calculation  is  to  count 
back  three  months  from  the  date  of  intercourse. 

If  impregnation,  instead  of  occurring  just  after  the  last  regular  period, 
occurred  just  before  the  next  period,  this  period  is  usually  not  entirely 
absent  but  is  markedly  diminished.  Unless  attention  is  called  to  the  fact 
that  this  menstruation  was  much  less  than  normal  the  calculation  might 
be  based  on  the  date  of  the  first  day  of  this  flow  and  the  date  of  the 
expected  labor  be  placed  much  later  than  would  really  occur.  This  is 
one  of  the  instances  where  a  menstrual  flow  occurs  after  pregnane}-  has 
started. 

There  are  several  other  methods  for  computing  the  date  of  the  expected 
confinement,  one  being  that  of  ^Mathews  Duncan,  which  takes  the  last 
day  of  the  last  menstruation  and  adds  nine  months,  which  is  regarded 
as  two  hundred  and  seventy-five  days ;  to  this  add  three  days  or,  if  February 
comes  in  these  nine  months  add  five  days,  making  two  hundred  and 
seventy-eight  days.  This  date  will  be  the  middle  of  the  fortnight  in  which 
labor  occurs.  According  to  the  Duncan  rule,  if  the  patient's  last  menstrua- 
tion began  September  10,  it  would  probably  end  September  15.  Adding 
nine  months  to  this  would  make  June  15;  now  as  February  was  included 
in  these  nine  months  add  five  days,  which  would  make  June  20  as  the 
date  for  the  confinement  instead  of  June  17,  calculated  by  the  Xaegele 
rule.  The  date  of  the  first  day  of  the  last  menstruation  is  much  more 
apt  to  be  fixed  in  the  patient's  mind  or  on  her  calendar  than  is  the  last 
day  of  that  period,  and  in  the  experience  of  the  author  the  Xaegele  rule 
forms  a  better  working  method  than  does  that  of  Duncan. 

Sometimes  pregnancy  occurs  during  a  considerable  period  of  amenor- 
rhea, caused  by  lactation,  anemia,  or  other  conditions,  and  the  patient 
is  perhaps  surprised  by  the  enlargement  of  the  abdomen  or  by  fetal 
movements.  If  the  patient  is  nursing  her  child,  the  first  intimation  of 
pregnancy  may  be  that  her  milk  suddenly  decreases  in  quantity  or  diges- 
tibility for  the  infant. 

The  difficulties  in  the  way  of  estimating  the  date  of  confinement 
under  these  circumstances  are  very  evident,  and  the  obstetrician  usually 
has  to  rely  upon  the  height  to  which  the  fundus  of  the  uterus  has  risen, 
in  the  abdomen. 

At  the  fourth  month  the  fundus  is  usually  felt  distinctly  above  the 
s>Tnphysis  pubis;  at  the  fifth  month  midway  between  the  sj-mphysis 
and  the  imibilicus;  at  the  sixth  month  at  the  level  of  the  umbilicus;  at 
the  seventh  month  about  four  fingers'  breadth  above  the  umbilicus; 
at  the  eighth  month  two-thirds  of  the  distance  between  the  umbilicus 


OBSTETRICIAN'S  ARMAMENTARIUM  165 

and  the  ensiform  cartilage.  At  the  early  part  of  the  ninth  month  the 
fundus  reaches  nearly  to  the  level  of  the  ensiform  cartilage.  During 
the  last  two  weeks  of  pregnancy  as  the  presenting  part  enters  the  pelvic 
brim  the  fundus  descends  until  it  reaches  about  the  level  it  occupied  at 
the  eighth  month.  There  are  naturally  many  sources  of  possible  error 
in  calculating  the  duration  of  pregnancy  in  this  manner.  The  umbilicus 
is  not  always  at  the  same  height;  the  uterine  body  may  be  abnormally 
large  from  the  presence  of  twins  or  hydramnios;  extreme  laxity  of  the 
abdominal  wall  may  allow  changes  in  the  position  of  the  uterus  and  non- 
engagement  of  the  presenting  part,  and  excessive  fat  in  the  abdominal 
wail  may  interfere  with  accurate  palpation  of  the  fundus. 

Careful  observation  of  the  height  of  the  fundus  taken  in  connection 
with  careful  palpation  of  the  fetus,  both  externally  and  bimanually, 
will  usually  enable  the  approximate  duration  of  pregnancy  to  be  arrived 
at.  On  account  of  the  variations  in  the  height  of  the  umbilicus  above 
the  symphysis,  as  shown  by  Spiegelberg,^  it  has  been  thought  best  by  some 
to  estimate  the  duration  of  pregnancy  by  measuring  the  height  of  the 
fundus  above  the  symphysis  with  a  tape-measure  rather  than  comparing 
it  with  the  umbilicus.  The  results  obtained  by  Spiegelberg  in  the  use 
of  this  method  are  as  follows: 

22d  to  28th  week 24 . 0  to  24 . 5  centimeters 

28th  week 26.7 


30th 

32d 

34th 

36th 

38th 

40th 


28.4 
29.5  to  30.0 
31.0 
32.0 
33.1 
33.7 


According  to  McDonald^  the  duration  of  pregnancy  in  lunar  months 
equals  height  of  the  uterus  in  cm.  (above  the  symphysis)  divided  by  three 
and  one-half.  These  measurements,  however,  vary  so  greatly  in  different 
people  that  for  practical  purposes  the  comparison  of  the  fundal  height 
with  the  umbilicus  is  more  useful.  The  time  of  feeling  life  or  quickening 
has  frequently  been  used  as  a  basis  of  calculation  in  estimating  the  date 
of  confinement,  it  being  the  rule  that  fetal  movements  are  usually  felt 
at  about  four  and  a  half  months.  This  rule,  however,  is  subject  to 
many  exceptions,  since  in  some  women  who  have  previously  borne 
children  and  have  experienced  the  sensation  of  "life"  this  is  felt  much 
earlier,  while  in  others  it  is  not  felt  until  considerably  later.  In  some, 
moreover,  the  movement  of  gas  in  the  intestines  and  other  sensations  or 
imaginations  are  mistaken  for  "  life."  Taken  in  connection  with  the  height 
of  the  fundus  and  the  history  of  the  case  the  time  of  feeling  life  may  be 
of  considerable  value  in  estimating  the  date  of  confinement.  By  itself 
it  has  little  value. 

Obstetrician's  Armamentarium.— With  the  growth  of  modern  ob- 
stetrics there  has  grown  the  obstetric  bag,  both  in  size  and  contents. 

1  Lehrbuch  der  Geburtshiilfe,  III  aufl.,  1891,  pp.  126-127. 

2  Mensuration  of  the  Child  in  the  Uterus  with  New  Methods,  Jour.  Am.  Med.  Assn., 
December  15,  1906,  xlvii.  1979  to  1983. 


166 


THE  MANAGEMENT  OF  NORMAL  PREGNANCY 


Tlie  long,  narrow  black  bag  so  popnlar  \\ith  obstetricians  twenty  years 
ago  has  been  relegated  to  the  past  as  entirely  unfit  for  the  uses  of  the 
present  day. 

There  are  many  styles  of  obstetric  bags  on  the  market,  but  in  the  opinion 
of  the  author  the  best  obstetric  bag  is  an  ordinary  dress-suit  case  contain- 
ing two  copper  trays:  a  long  one  measuring  on  the  inside  18  inches  in 
length,  6  inches  in  width,  and  4  inches  in  height;  and  a  short  one  10  inches 
in  length,  5f  inches  in  width,  and  3f  inches  in  height,  each  with  covers 
and  the  short  tray  just  wide  enough  and  high  enough  to  fit,  with  cover 
on,  into  the  long  tray  and  allow  its  cover  to  fit. 


Fig.   113. — Author's  bag  with  trays  and  covers. 


The  author's  bag  and  contents  are  shown  in  Figs.  113  and  114.  The 
object  of  two  trays  is  to  have  one  long  enough  to  boil  a  pair  of  forceps  in, 
and  a  smaller  one  for  boiling  small  instruments  like  a  perineorrhaphy 
set,  the  smaller  tray  being  much  more  convenient  for  ordinar\-  use  in 
cases  which  do  not  require  the  forceps.  In  time  of  need  the  long  tray 
can  be  used  for  hand  solution. 

In  these  two  trays  can  be  carried  man}'  of  the  articles  so  necessary 
to  the  obstetrician,  and  outside  the  trays  can  be  carried  the  forceps  and 
miscellaneous  articles.  It  is  well  to  have  a  special  place  in  the  bag  for 
each  article  so  that  an  inspection  will  show  at  a  glance  whether  the  bag 
is  properly  packed  or  not,  and  also  that  in  case  of  haste,  the  article 


OBSTETRICIAN'S  ARMAMENTARIUM 


167 


Fig.  114. — Author's  bag  packed. 


Fig.  115. — Perineorrhaphy  set  and  short  instruments  often  needed. 


168  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

needed  can  l)e  found  at  once.  A  reference  to  Figs.  114  and  115  will  show 
the  articles  carried  by  the  author  and  tluMr  proper  place  in  the  hag.  In 
the  smaller  tray  are  carried: 

1.  Box  containing  ruhber  elastic  dilators  (XOorhces'  bags). 

2.  Box  containing  syringe  for  distending  elastic  dilators. 

3.  Perineorrhaph\'  and  short  instruments  (see  Fig.  115). 

4.  Rubber  gloves. 

In  the  large  tray  are  carried. 

1.  Bottles  of  solutions:  (a)  Ergot;  (b)  chloroform;  (c)  ether;  (d) 
argyrol,  20   per    cent,    solution,  for   babv's   eves;    (e)   tr.   green  soap; 

(/)  lysol. 

2.  Catgut  in  tubes. 

3.  Bottle  of  bichloride  tablets. 

4.  Small  scales. 

Outside  the  trays  are  carried:  (a)  stethoscope;  (6)  pair  of  Tucker- 
INIcLane  forceps:  (c)  pair  of  axis-traction  forceps;  (d)  chloroform  mask; 
(e)  rubber  apron;  (/)  sterilized  gown;  (g)  sterilized  bougie  in  tube;  (A) 
sterilized  stilet  in  tube;  (i)  sterilized  scrubbing  brush;  (j)  sterilized 
douche  bag;  (k)  sterilized  douche  nozzle;  (/)  tube  of  sterilized  iodoform 
gauze;  (m)  tube  of  sterilized  plain  gauze;  (n)  sterilized  soft-rubber  catheter 
(o)  sterilized  glass  catheter;  (p)  leg  holder. 

The  dress-suit  case  has  many  advantages  for  an  obstetric  bag  over  the 
ordinary  hand  satchel.  The  contents  are  heavy  and  this  amount  of  weight 
can  be  carried  much  more  easily  in  something  thin  like  a  dress-suit  case 
which  hangs  by  one's  side,  than  in  a  broader,  bulging  satchel.  Further- 
more, the  square  corners  of  a  suitcase  allow  many  articles  to  be  packed 
with  an  economy  of  space. 

Obstetric  Outfit  for  Patient. — The  advantages  of  having  everything 
to  be  used  about  the  patient  in  labor  thoroughly  sterilized  and  prepared 
beforehand  are  so  great  that  it  has  become  the  custom,  where  the  patient 
can  afford  it,  to  have  her  order  one  of  the  obstetric  outfits,  of  which  there 
are  many  on  the  market,  making  sure  that  the  articles  are  thoroughly 
sterilized.  One  of  the  best  contains  the  following  articles:  Two  sterilized 
bed  pads  (30  inches  square);  2  dozen  sterilized  vulva  pads;  2  sterilized 
mull  binders  (18  inches  wide);  6  sterilized  towels:  10  yards  sterilized 
gauze;  1  pound  sterilized  absorbent  cotton  (^-pound  packages);  rubber 
sheet,  1  yard  by  1^  yards,  sterilized;  rubber  sheet,  1|  yards  by  2  yards, 
sterilized;  4-quart  sterilized  douche  bag  with  glass  nozzle;  douche  pan, 
sterilized;  sterilized  nail  brush;  2  agate  basins,  sterilized;  safety  pins; 
2  tubes  sterilized  petrolatum;  boric  acid,  powdered;  100  grams  chloro- 
form (Squibb's);  fluidextract  ergot;  tincture  green  soap;  lysol;  tube 
sterilized  tape;  sterilized  soft-rubber  catheter;  sterilized  glass  catheter; 
stocking  drawers,  sterilized;  talcmn  powder;  bath  thermometer. 

Each  article  is  wrapped  in  a  separate  package  and  separately 
sterilized. 

The  outfit  should  be  in  the  patient's  home  a  month  before  the  expected 
confinement,  and  should  only  be  opened  by  the  doctor  or  nurse. 

The  comfort  of  the  obstetrician  in  having  at  his  command  an  outfit 


ANTEPARTUM  EXAMINATION  169 

upon  which  he  can  rely,  both  as  to  contents  and  sterility,  can  only  be 
appreciated  by  those  who  have  worked  both  with  and  without  it. 

The  expense,  although  quite  an  item,  is  more  than  counter-balanced 
by  the  additional  safeguarding  of  the  patient. 

Antepartum  Examination. — If  one  has  an  office  nurse,  which  is  almost 
a  necessity  if  he  is  to  do  much  work  in  obstetrics  or  gynecology,  the  most 
satisfactory  place  for  the  preliminary  pelvic  examination  is  the  office. 

For  the  easy  performance  of  this  work,  however,  a  certain  arrangement 
of  offices  is  desirable.  ^Yhatever  the  plan  of  the  reception-room  may  be 
the  arrangement  of  consulting-room,  and  examining-room  should  be  such 
that  the  patient  can  go  from  consulting-room  to  examining-room  and  from 
there  to  the  dressing-room  and  toilet  without  returning  to  the  consulting- 
room. 

From  the  examining-room  the  patient  should  also  be  able  to  pass  out 
of  the  house  without  returning  to  the  consulting-room.  The  plan  of  offices 
which  in  my  experience  has  proved  most  convenient  is  sho'^ii  in  Fig.  116, 
the  patient  being  enabled  to  go  from  examining-room  to  dressing-room 
and  toilet  as  needed  and  through  dressing-room  to  house  exit  without 


\S5, 


DRESS 


EXAMINING  ^7     ANDTOUET^^ 


FT } 

L./  HALL  / 


ROOM 


A 


Y.....  J 


CONSULTING  ]  reception    |  RECEPTION 

I  I 

ROOM  I       ROOM        I  ROOM 


J I 


Fig.  116. — Plan  of  ofBces. 

reentering  consulting-room,  thus  enabling  the  obstetrician  to  see  patient 
No.  2  while  No.  1  is  dressing.  It  is  understood,  of  course,  that  a  young 
man  just  starting  in  practice  may  find  it  impossible  to  have  either  office 
nurse  or  more  than  one  office,  yet  there  is  always  benefit  in  studying  what 
is  best  suited  for  one's  work  and  then  striving  to  approach  it  as  nearly 
as  possible. 

After  taking  a  careful  history  of  the  patient,  she  should  be  requested 
to  step  into  the  examining-room  and  the  nurse  asked  to  prepare  her 
for  examination.  The  nurse  takes  her  to  the  dressing-room  where 
she  removes  her  corsets  and  a  specimen  of  the  urine  is  obtained. 
The  patient  is  then  arranged  for  pelvimetry  on  the  examining  table. 
As  a  rule  a  table  will  be  found  more  convenient  for  office  work 
than  any  of  the  numerous  examining  chairs  on  the  market.  The 
table  need  not  be  a  complicated  one;  a  simple  one  is  preferable. 
What  is  needed  is  a  strong  table  with  a  broad  step  to  assist  in  mounting 
and  a  foot-board  containing  a  heel-hole  which  can  be  pulled  out  on  either 
side  of  the  foot  of  the  table.  These  foot-boards  support  the  feet  when 
the  patient  is  in  the  lithotomy  position  and  the  legs  when  she  is  on  her 
side.    The  table  should  be  cushioned  with  a  thin  mattress  covered  with 


170  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

a  clean  sheet  and  provided  with  a  small  pillow.  A  very  good  way  to 
arrange  the  sheet  is  to  have  the  length  of  it  across  the  table  so  that 
enough  is  free  to  cover  the  patient  when  she  is  on  the  table.  Many  of 
the  tables  are  made  of  metal,  although  when  used  for  examination  pur- 
poses only  there  are  certain  advantages  in  wooden  tables  painted  with 
white  enamel.  They  are  lighter,  warmer  in  winter,  and  less  expensive. 
For  pelvimetry  the  patient  is  first  placed  in  the  dorsal  position,  the 
waist  and  undervest  drawn  up  to  the  lower  border  of  the  ribs  and  the 
skirts  drawn  down  to  the  level  of  the  trochanters.  In  this  way  enough 
of  the  patient's  abdomen  and  back  is  exposed  for  all  ordinary  pelvimetry 
save  that  of  the  outlet  which  will  come  later.  The  ordinary  measurements 
taken  in  external  pelvimetry  are  the  folloAying: 

(a)  Distance  between  anterior  superior  iliac  spines,  called  the  inter- 
spinous  diameter. 

(b)  Distance  between  iliac  crests,  called  intercristal  diameter. 

(c)  Distance  between  left  posterior  superior  iliac  spine  and  right 
anterior  superior  iliac  spine,  called  left  oblique  diameter. 

(d)  Distance  between  right  posterior  superior  iliac  spine  and  left 
anterior  superior  iliac  spine,  called  right  oblique  diameter.  ^ 

(e)  Distance  between  sulcus  just  beneath  spine  of  last  lumbar  vertebra 
and  the  upper  anterior  border  of  the  symphysis  pubis,  called  the  external 
conjugate  or  Baudelocque's  diameter. 

(/)  Distance  between  the  tuberosities  of  the  ischium,  called  the  trans- 
verse diameter  of  the  outlet. 

The  distance  between  the  under  surface  of  the  symphysis  and  the  tip 
of  the  sacrum,  called  the  anteroposterior  diameter  of  the  outlet,  is  sometimes 
taken  but  is  of  little  value,  as  in  contracted  pelves  the  pubic  arch  is  so 
narrow  that  but  little  of  the  space  is  available  for  the  fetal  head. 

There  are  several  good  pelvimeters  on  the  market,  but  the  one  used  by 
the  author,  both  at  the  Sloane  Hospital  and  in  his  private  practice,  is  the 
Breisky,  a  modification  of  Baudelocque's,  which  is  broad  enough  to 
surround  the  patient's  hips  in  taking  the  oblique  and  external  conjugate 
diameters,  yet  rigid  enough  to  give  accurate  measurements.  The  method 
of  taking  the  measurements  is  as  follows :  With  the  patient  in  the  dorsal 
position,  the  tips  of  the  pelvimeter  are  held  between  the  thumb,  index 
and  middle  fingers  of  each  hand.  Facing  the  head  of  the  patient  and 
holding  the  pelvimeter  with  index  upward,  the  tips  are  placed  on  each 
anterior  superior  iliac  spine  (see  1  and  2,  Figs.  117  and  118)  and  the  reading 
taken.  The  tips  of  the  pelvimeter  are  then  slid  along  the  crest  of  the  ilia 
and  the  reading  of  the  greatest  amount  of  separation  taken  as  the  inter- 
cristal diameter  (see  3  and  4>  Figs.  117  and  118). 

The  patient  is  then  turned  into  the  left  lateral  or  Sims' s  position,  and 
with  the  obstetrician  facing  the  head  of  the  table,  the  distance  is  measured 
from  the  left  posterosuperior  iliac  spine  to  the  right  anterosuperior 
iliac  spine  (see  5  in  Figs.  119  and  120  and  2  in  Fig.  118).  The  location 
of  each  posterosuperior  iliac  spine  is  usually  indicated  by  a  dimple 
which  with  the  dimple  caused  by  the  depression  under  the  spine  of  the 
last  lumbar  vertebra  and  the  one  over  the  lower  part  of  the  sacrum 


ANTEPARTUM  EXAMINATION 


171 


forms  what  is  called  the  rhomboid  of  Michaelis  (see  Fig.  121).  These 
four  points  are  often  not  all  visible  and  one  frequently,  especially  in  fleshy 
women,  has  to  locate  the  depression  beneath  the  last  lumbar  spine  by 


Fig.   117. —  Mensuration  of  iiitcrspinous  and  intercristal  diameters. 


10  9 

Fig.   118. — Pelvis  showing  points  taken  in  mensuration. 


172 


THE  MANAGEMENT  OF  NORMAL  PREGNANCY 


Fig.  119. — Mensuration  of  the  left  oblique  diameter. 


Fig.  120. — Pelvis  showing  points  taken  in  mensuration. 


ANTEPARTUM  EXAMINATION 


173 


the  sense  of  touch  alone.  The  dimples  over  the  posterosuperior  iliac 
spines,  however,  are  usually  visible  in  proper  light  and  are  of  value  to  the 
beginner  in  pelvimetry. 


1  Ij 

w]^J 

^Ik^             -^""^^^fK 

Fig.  121. — Dimples  forming  the  rhomboid  of  :Micluieli; 


Fig.   122. — Mensuration  of  right  oblique  diameter. 


174  THE  MANAGEMENT  OF   NORMAL   rRECXANCY 

f5 


Fig.   124. — Mensuration  of  external  conjugate  diameter. 


ANTEPARTUM  EXAMINATION 


-    175 


The  patient  is  now  turned  upon  her  right  side  and,  with  the  examiner 
facmg  the  foot  of  the  table,  the  right  obhque  diameter,  from  the  tip  ot 


Fig.  125.— Pelvis  showing  points  taken  in  mensuration. 


Fig 


.  126.— Mensuration  of  the  transverse  diameter  of  the  outlet. 


the  right   posterosuperior   ihac   spine   to   t^e  tip   of  the   left   ant^ero- 
supeS  ilia^c  spine  (see  6  in  Figs.  122  and  123  and  1  m  Fig.  118)  is  taken. 


17G  THE   MAXAGEMEXT  OF  XORMAL  PREGXANCY 

This  right  obhque  diameter  of  the  pelvis  is  usualh'  a  trifle  longer  than  the 
left. 

With  the  patient  still  in  the  right  lateral  position  the  external  conju- 
gate diameter  is  measured.  The  posterior  point  taken  is  the  depression 
just  below  the  spine  of  the  last  lumbar  vertebra,  and  with  one  tip  of  the 
pelvimeter  placed  in  this  position  (see  7  in  Figs.  123  and  124),  the  other 
tip  is  carried  between  the  patient's  thighs  and  placed  upon  the  anterior 
upper  border  of  the  symphysis  (see  8  in  Fig.  123). 

For  taking  the  transverse  diameter  of  the  outlet  the  patient  is  placed 
in  the  lithotomy  position  and  the  examiner,  locating  the  tul)erosities  of 
the  ischia  with  his  thumbs,  as  illustrated  in  Fig.  126,  measures  the  distance 
with  the  pelvimeter  between  the  points  9  and  10. 

While  marked  variations  occur  in  the  external  measurements  of  different 
pelves  called  normal,  it  is  well  for  the  student  to  have  in  mind  certain 
measurements  which  may  be  regarded  as  normal.  The  following  may  be 
considered  as  such,  and  for  ease  of  memory  fractions  will  be  omitted: 

External  Measurements  of  Normal  Pelvis. 

Intcrspinous  diameter    ...      26  cm.  Right  oblique  diameter  .      22  +  cm. 

Intercristal  diameter      ...      28  cm.  External  conjugate  diameter    .  20  cm. 

Left  oblique  diameter    ...      22  cm.  Transverse  diameter  of  the  outlet      11  cm. 

Value  of  External  Pelvimetry. — It  is  well  known  that  pelvimetry,  and 
especially  external  pelvimetry,  cannot  be  depended  upon  alone.  The 
author  has  met  with  a  number  of  cases  giving  marked  dystocia,  perhaps 
even  requiring  Cesarean  section  for  deli^'e^y,  in  which  pelvimetry  gave 
him  no  indication  that  the  labor  was  to  be  anything  but  normal.  This 
is  not  difficult  to  understand  when  there  is  considered  the  fact  that 
obstruction  at  the  brim  produced  by  the  lower  lumbar  ^•erteb^a?  is  often 
not  indicated  in  external  pelvimetry  and  may  be  situated  too  high  to 
be  reached  by  the  examining  fingers  in  the  vagina. 

External  pelvimetry  has  value,  however,  and  often  great  value  in  diag- 
nosis of  abnormal  pelves  and  by  giving  information  which  otherwise 
might  come  as  a  surprise  to  the  obstetrician  during  labor,  finding  him 
unprepared  for  dealing  with  complications  which  should  have  been  met 
by  prophylaxis. 

While  the  interspinous  and  intercristal  diameters  by  themselves  are 
often  of  little  value,  their  relative  measurements  are  of  great  value  in 
diagnosis.  If  they  are  about  equal,  and  especially  if  the  interspinous 
diameter  exceeds  the  intercristal,  the  pelvis  is  probably  rachitic. 

The  oblique  diameters  give  valuable  information,  both  as  to  the  general 
size  of  the  pelvis,  i.  e.,  whether  it  is  generally  contracted  or  not,  and  also 
show  whether  the  pelvis  is  symmetrical  or  not,  i.  e.,  discloses  an  obliquely 
contracted  pehis. 

The  external  conjugate  varies  greatly  in  size  in  different  individuals 
and  often  gives  little  information  of  value.  If,  however,  the  external 
conjugate  measures  only  18  cm.  or  less,  it  is  often  a  forerunner  of  dystocia, 
and  should  indicate  a  very  careful  pelvic  examination. 

The  measurement  of  the  transverse  diameter  of  the  outlet  and  the 


THE  PRESENTATION  AND  POSITION  OF  THE  CHILD        177 

palpation  of  the  shape  of  the  pubic  arch  give  valuable  information  as 
to  the  presence  or  absence  of  a  funnel-shaped  pelvis  or  one  contracted 
at  the  outlet. 

Having  ascertained  the  external  characters  of  the  pelvis,  the  abdomen 
and  its  contents  should  now  be  inspected  and  palpated.  The  occasional 
occurrence  of  dystocia  resulting  from  previous  operations  upon  the 
pelvic  organs  makes  it  wise  always  to  inspect  the  abdomen  for  cicatrices 
and  to  ascertain  if  possible  the  character  of  the  operation  to  which  the 
patient  has  been  subjected.  The  abdomen  should  also  be  palpated  for 
abdominal  tumors  other  than  the  pregnant  uterus.  So  much  knowledge 
can  be  obtained  by  palpation  of  the  pregnant  uterus  through  the  abdom- 
inal wall  during  the  last  third  of  pregnancy  that  the  student  should 
endeavor  to  make  himself  an  expert  in  this  direction.  Furthermore,  the 
recognition  of  the  fact  that  each  vaginal  examination  in  the  later  weeks 
of  pregnancy  adds  to  the  risk  of  maternal  infection  makes  it  desirable 
to  substitute,  as  far  as  possible,  abdominal  examinations  for  vaginal. 
Aside  from  the  information  regarding  the  condition  of  the  abdominal 
wall,  the  presence  of  tumors  and  the  size  of  the  uterine  body,  the  follow- 
ing facts  can,  in  the  latter  third  of  pregnancy,  usually  be  determined  by 
skilled,  careful  palpation  of  the  uterus  through  the  abdominal  wall. 

The  Presentation  and  Position  of  the  Child. — Presentation  may  be 
defined  as  the  relation  which  the  long  axis  of  the  fetus  bears  to  that 
of  the  mother,  thus  a  longitudinal,  an  oblique,  or  a  transverse  presen- 
tation (see  page  244).  A  presentation  is  usually  named  from  the  "pre- 
senting part"  which  is  that  part  of  the  fetus  which  lies  over  the  cervix 
and  is  felt  by  the  examining  fingers.  Thus  a  vertex  presentation,  a 
breech  presentation,  etc. 

Position  is  the  relation  of  a  selected  position  of  the  presenting  part 
to  certain  fixed  landmarks  in  the  maternal  pelvis  (see  page  248).  If 
the  examination  is  made  during  the  early  months  of  pregnancy  and 
the  uterus  is  palpable  above  the  pelvic  brim,  this  palpation  should 
be  made  to  see  if  the  size  corresponds  with  the  supposed  duration  of 
pregnancy.  During  the  latter  part  of  pregnancy  the  palpation  should 
be  thorough  and  all  available  information  obtained. 

It  is  always  well  to  have  a  definite  order  in  any  careful  examination 
and  the  one  recommended  by  the  author  is  as  follows: 

Location  of  the  Fetal  Back  and  Small  Parts. — Standing  with  face  toward 
the  patient's  feet  (see  Fig.  127),  the  examiner  carefully  palpates  both  sides 
of  the  abdomen  with  the  palmar  surfaces  of  the  fingers,  gently  moving 
them  up  and  down.  On  one  side  is  usually  felt  the  broad,  smooth  back 
of  the  fetus  and  on  the  other  side  the  irregular  nodules  of  the  small  parts. 

This  is  sometimes  brought  out  more  distinctly  by  pressing  gently  with 
the  hand  on  the  side  where  the  small  parts  are,  thus  forcing  the  back 
of  the  fetus  up  against  the  abdominal  wall  (see  Figs.  128  and  129).  In 
women  with  thin  abdominal  walls  the  nodules  can  often  be  differentiated 
into  arms  and  legs,  but  with  fat  abdominal  walls  this  is  impossible.  The 
presence  of  the  small  parts  on  one  side  means,  except  in  the  case  of  twins, 
that  the  back  is  on  the  other. 
12 


178 


THE  MANAGEMENT  OF  NORMAL  PREGNANCY 


Having  determined  upon  which  side  the  back  of  the  child  Hes,  the  next 
step  is  to  decide  whether  it  Hes  anteriorly,  laterally,  or  posteriorly. 


Fig.   127. — Palpation  of  the  fetal  back  and  small  parts. 


Fi*;-   12S. — Fetal  Viaek  occupying  left  side  of  abdomen  (L.  O.  A.  ijujitioiij.     Right  side  of 
abdomen  occupied  by  small  parts  easily  depressed  by  hand. 


THE  PRESENTATION  AND  POSITION  OF   THE  CHILD        179 

This  is  determined  by  the  amount  of  the  broad,  smooth  surface  which 
can  be  felt.    If  the  back  lies  anteriorly  the  most  of  this  convex  surface 


Fig.   129. — Fetal  back  occupying  right  side  of  abdomen  (R.  O.  A.  position). 
of  abdomen  occupied  by  small  parts  easily  depressed  by  hand. 


Left  side 


Fig.   130. — Palpation  of  the  lower  fetal  pole. 

can  be  felt.  If  it  lies  laterally  the  surface  felt  is  narrower  and  shows  a 
sulcus  between  the  fetal  head  and  shoulder.  Furthermore,  the  nodula- 
tions  of  the  upper  and  lower  extremities  are  more  distinct.    If  the  fetal 


180 


THE  MANAGEMENT  OF  NORMAL  PREGNANCY 


back  lies  posteriorly,  little  of  this  dorsal  surface  of  the  fetus  can  be  felt, 
but  the  small  parts  lie  anteriorly,  enabling  one  to  feel  the  various  nodules 
presented  by  them. 

Palpation  of  the  Presenting  Fetal  Pole. — Still  facing  the  feet  of  the  patient 
the  examiner  (see  Fig.  130)  passes  his  hands,  applied  flat  upon  the  abdo- 
men, down  toward  the  brim  of  the  pelvis.  If  the  head  presents,  the  fingers 
of  one  hand  at  least  soon  impinge  upon  a  hard,  round  body,  the  cephalic 
extremity.  This  feeling  of  a  hard,  round  body  separated  from  the 
trunk  by  the  constriction  of  the  neck  determines  the  fact  of  a  cephalic 
presentation. 

If  the  presenting  part  has  descended  into  the  pelvis  before  labor, 
it  is  an  evidence  that  the  lower  part  of  the  fetus  is  cephalic  rather  than 
the  breech,  which  does  not  descend  until  labor  begins. 


P^iG.   131. — Palpation  of  the  upper  fetal  pole. 

The  feel  of  the  breech  is  not  as  distinct  as  is  that  of  the  head,  and  the 
positive  diagnosis  of  a  breech  presentation  by  abdominal  palpation  is 
usually  made  by  finding  the  head  elsewhere.  In  transverse  presentations 
the  lower  fetal  pole  lies  in  one  iliac  fossa. 

Having  determined  that  the  presentation  is  cephalic,  the  next  step  is 
to  make  out  the  position  of  the  head.  In  vertex  presentations  the  promi- 
nence arresting  the  fingers  is  on  the  same  side  as  the  small  parts  of  the 
fetus,  while  in  face  presentations  the  prominence  is  on  the  same  side  as 
the  back.  In  vertex  presentations,  as  the  prominence  felt  corresponds 
with  the  forehead,  the  ease  with  which  it  can  be  felt  tells  the  degree 
of  flexion  of  the  head  and  its  descent  into  the  pel;^is. 


THE  PRESENTATION  AND  POSITION  OF  THE  CHILD        181 

This  method  of  examination  is  of  value  not  only  during  the  latter 
months  of  pregnancy  but  also  during  labor,  as  by  it  can  be  determined, 
in  the  intervals  between  uterine  contractions,  not  only  the  presentation 
and  position  of  the  child  but  also  the  amount  of  its  descent  into  the 
pelvis. 

Palpation  of  the  Upper  Fetal  Pole. — For  this  manipulation  the  examiner 
faces  the  patient's  head  and  applies  the  palmar  surface  of  the  fingers  to 
the  fundus  of  the  uterus  (see  Fig.  131).  By  gentle  palpation  can  be 
differentiated  the  hard,  round,  movable  head  which  may  be  subjected  to 
ballottement  from  the  softer,  less  movable,  irregularly  shaped  breech 
with  the  nodules  of  the  small  parts  near  it. 

During  uterine  contractions  careful  palpation  will  often  detect  the 
presence  of  small  fibroid  tumors,  should  any  exist,  and  by  palpating 
between  the  internal  abdominal  rings  and  the  fundus  of  the  uterus 
can  often  easily  be  made  out  the  round  ligaments  which  can  be  rolled 
under  the  fingers. 

Some  authorities  advocate,  as  a  step  in  the  routine  method  of  examina- 
tion, the  grasping  through  the  abdominal  wall  of  the  lower  fetal  pole 
between  the  thumb  and  fingers  of  one  hand  and  by  palpation  and  test- 
ing its  mobility  gaining  such  information  as  is  possible.  It  seems  to  the 
author,  however,  that  little  is  gained  by  this  that  is  not  possible  in  the 
methods  already  outlined.  By  careful  practise  with  the  three  methods 
above  described,  each  time  trying  to  learn  as  much  as  possible  at  each 
step  in  the  procedure,  the  student  becomes  expert  in  diagnosis  by 
external  manipulation  and  learns  to  depend  less  and  less  upon  vaginal 
examination. 

Auscultation  of  the  Fetal  Heart. — ^The  recognition  of  the  importance 
of  careful  observation  of  the  fetal  heart  sounds,  especially  during  labor, 
has  grown  in  recent  years.  So  important  during  labor  are  marked  changes 
in  its  normal  beat  as  indicating  excessive  or  too  prolonged  pressure  that 
the  obstetrician  should  regard  the  auscultation  of  the  fetal  heart  during 
pregnancy  as  important,  not  only  for  verifying  his  diagnosis  of  the  presen- 
tation and  position  of  the  child  but  as  giving  him  information  as  to  the 
normal  heart  sounds  of  the  individual  case  with  which  he  may  contrast 
the  findings  during  labor.  The  fetal  heart  sounds  are  usually  transmitted 
through  the  portion  of  fetal  trunk  which  is  in  contact  with  the  abdominal 
wall  of  the  mother,  i.  e.,  usually  through  the  back  of  the  fetus  in  vertex 
and  breech  presentations  and  through  the  anterior  thorax  in  face  pre- 
sentations. It  is  evident,  therefore,  that  the  site  of  greatest  intensity  of 
the  fetal  heart  sounds  will  often  indicate  the  presentation  and  position 
of  the  child  and  the  approach  of  this  site  toward  the  median  line  and 
toward  the  symphysis  pubis  will  mark  the  rotation  and  descent  of  the 
child  in  labor. 

Various  factors  may  interfere  with  the  ability  to  hear  the  fetal  heart. 
Among  them  may  be  mentioned  a  very  fat  abdomen,  an  excessive  amount 
of  liquor  amnii,  an  occipitoposterior  position  of  the  child,  an  anterior 
attachment  of  the  placenta  and  a  very  loud  uterine  souffle.  Of  course  if 
the  child  is  dead  the  fetal  heart  sounds  are  absent,  but  on  account  of  the 


182  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

difficulty  in  many  cases  of  obtaining  the  sound  even  if  the  child  is  alive, 
the  diagnosis  of  the  death  of  the  fetus  should  only  be  made  after  several 
examinations  and  when  taken  in  conjimction  with  other  symptoms  of 
fetal  death. 

The  character  of  the  fetal  heart  sounds  as  an  index  of  the  condition 
of  the  child  will  be  discussed  later;  suffice  it  for  the  present  to  state  that 
any  marked  irregularity  of  the  fetal  heart,  or  any  marked  increase  or 
decrease  in  its  rapidity,  as  compared  with  that  previously  noted  as  its 
normal  rate,  is  an  indication  of  a  disturbance  of  the  fetal  circulation  and 
is  important. 


Fig.   132. — Method  of  using  stethoscope  in  listening  to  the  fetal  heart. 

The  heart  sounds  may  be  heard  either  with  the  naked  ear  or  with 
the  stethoscope,  and  in  the  use  of  the  stethoscope  it  is  usually  of  assis- 
tance to  have  attached  to  it  two  rubber  bands,  as  shown  in  Fig.  132, 
with  which  the  instrument  can  be  steadied  and  with  which  its  press- 
ure against  the  abdominal  w^all  can  be  regulated  with  ease,  at  the  same 
time  avoiding  the  blurring  of  the  heart  sounds  which  comes  from  the 
vibrations  caused  by  holding  the  bell  of  the  stethoscope  with  the  fingers. 
In  cephalic  presentations  the  fetal  heart  sounds  are  usually  heard  most 
distinctly  below  the  level  of  the  umbilicus,  while  in  breech  presentations 
the  site  of  greatest  intensity  is  usually  above  the  umbilicus.  In  occipito- 
anterior positions  of  vertex  presentations  the  site  of  greatest  intensity 
is  usually  near  the  middle  of  the  line  joining  the  umbilicus  with  the 
anterosuperior  iliac   spine  of  that  side.     In  occipitoposterior  positions 


FETAL  HEART  RATE,  AGE  AND  SEX  OF   THE  CHILD        183 

the  fetal  heart  is  usually  heard  most  distinctly  outside  of  this  line 
and  nearer  the  flank.  As  the  most  usual  position  of  the  fetus  is  with 
head  presenting  and  back  to  the  left  and  anterior,  the  most  usual  site 
for  hearing  the  fetal  heart  sounds  is  about  the  middle  of  the  line  joining 
the  umbilicus  and  the  left  anterior  superior  spine  of  the  ilium.  The  next 
most  usual  site  is  the  corresponding  point  on  the  right  side  of  the  abdomen. 
Occasionally  in  occipitoposterior  positions  of  the  vertex  the  location  of  the 
heart  sounds  is  misleading,  as  in  some  cases  flexion  of  the  head  is  so  imper- 
fect that  the  thorax  is  crowded  up  against  the  anterior  abdominal  wall  and 
the  heart  sounds  are  transmitted  through  this  rather  than  the  back,  and  the 
idea  is  given  that  the  case  is  one  of  occipito-anterior  position  rather  than 
occipitoposterior. 

In  twin  pregnancy  tw^o  fetal  heart  sounds  should  be  heard,  synchronous 
neither  with  each  other  nor  with  the  mother's  pulse.  The  rapidity  of  the 
fetal  heart  sounds  varies  between  120  and  160. 

The  attempt  has  often  been  made  to  determine  the  sex  of  the  child 
by  the  rapidity  of  the  fetal  heart  beat.  In  order  to  determine  the  relation 
between  the  fetal  heart  rate,  weight  and  sex  of  the  child,  the  author  took 
5000  consecutive  normal  cases  at  the  Sloane  Hospital  in  which  the  fetal 
heart  was  counted  during  the  first  stage  of  labor  at  term  and  in  which 
the  baby  was  carefully  weighed  at  birth.  In  this  series  of  5000  there 
were  2577  males  and  2423  females. 

In  the  2577  males  the  average  fetal  heart  rate  was  141.86. 

In  the  2423  females  the  average  fetal  heart  rate  was  146.65. 

This  gave  the  average  fetal  heart  rate  in  the  5000  cases,  144.25. 

In  this  series  of  2577  males  the  average  birth  weight  was  7  pounds  4.1 
ounces. 

In  this  series  of  2423  females  the  average  birth  weight  was  7  pounds 
1.9  ounces. 

This  gave  the  average  birth  weight  in  the  5000  cases  as  7  pounds  3 
ounces. 

All  of  these  cases  were  at  term;  none  under  48  cm.  in  length  being 
included. 

For  a  long  time  it  was  thought  that  boys  were  heavier  at  birth  than 
girls;  that  the  heavier  child  had  the  slower  heart  rate;  hence,  that  a  slow 
fetal  heart  rate  (around  120)  indicated  a  boy  or  a  large  girl,  and  that  a 
rapid  fetal  heart  rate  (around  160)  indicated  a  girl  or  a  small  boy.  A 
comparison  of  the  fetal  heart  rate  and  birth  weight  in  the  above  series 
shows  that  while  the  average  weight  of  the  boys  was  a  little  greater  than 
that  of  the  girls  and  the  average  heart  rate  of  the  boys  was  a  little  slower 
than  that  of  the  girls,  the  difference  was  so  slight  as  to  render  the  fetal 
heart  rate  of  very  little  practical  value  in  determining  the  sex  of  the 
child  before  birth.  This  is  still  further  shown  by  the  fact  that  in  400 
cases  in  the  above  series  in  which  the  birth  weight  was  6  pounds  or  less, 
the  fetal  heart  rate  averaged  144.67,  while  in  100  cases  in  which  the  birth 
weight  was  8  pounds  or  over,  the  fetal  heart  rate  averaged  145.09. 
This  series  of  5000  cases  indicates  that  in  New  York  City  at  least  the 
number  of  male  births  slightly  exceeds  that  of  the  females— 2577  males; 


184  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

2423  females.  This  corresponds  with  the  vital  statistics  of  the  Board  of 
Health  of  the  City  of  New  York  which  for  the  years  1912,  1913,  and  1914 
were  as  follows: 

Male.  Female. 

fWhite 68,169  65,046 

1912{Black 1,245  1,171 

[Chinese 11  13 

(White 67,926  64,773 

1913]  Black 1,236  1,176 

[Chinese 11  12 

f  White 70,315  67,810 

1914{Black 1,274  1,226 

[Chinese 13  9 

It  is  seen  from  the  above  that,  save  in  the  small  number  of  Chinese, 
the  males  exceeded  the  females,  and  this  has  been  the  case  for  a  long 
period  of  years. 

Vaginal  and  Bimanual  Examination. — Attention  has  already  been 
directed  to  the  fact  that  during  the  early  months  of  pregnancy  there 
are  marked  advantages  in  having  the  obstetrician  thoroughly  familiar 
with  the  condition  of  the  pelvic  organs  and  the  cavity  of  the  pelvis.  Of 
course  at  this  period  the  former  is  much  more  important  than  the  latter, 
but  in  making  a  thorough  examination  of  the  pelvic  organs  it  adds  but 
little  to  examine  the  pelvic  canal  at  the  same  time. 

In  making  a  vaginal  examination  during  the  early  months  of  pregnancy 
it  is  not  necessary  to  be  as  thorough  in  hand  disinfection  and  prepara- 
tion of  the  vulva  as  it  is  near  term,  yet  the  hands  should  always  be 
thoroughly  scrubbed  with  soap  and  water  and  the  examiner  should  culti- 
vate the  habit  of  always  separating  the  labia  with  the  fingers  of  one  hand 
before  introducing  the  examining  fingers  in  every  pregnant  patient,  so  as 
to  avoid  carrying  infection  from  vulva  without  to  vagina  w^ithin. 

In  this  examination  the  obstetrician  should  by  inspection  and  palpation 
carefully  note  the  condition  of  the  pelvic  floor;  the  height  of  the  vulva 
compared  to  the  pubic  arch,  and,  if  the  patient  is  a  multipara,  the  results 
of  the  previous  labor  or  labors.  He  should  also  carefully  examine  for 
evidences  of  gonorrheal  infection  in  the  ducts  of  the  vulvovaginal 
glands  and  urethra.  Noting  the  condition  of  the  vaginal  canal  and  the 
cervix  as  he  proceeds,  the  examiner  should  now  make  a  gentle  bimanual 
examination  and  determine  if  the  uterus  is  in  normal  position;  if  it 
presents  the  usual  characteristics  of  pregnancy,  if  the  size  corresponds 
with  the  supposed  duration  of  pregnancy  and,  lastly,  if  there  are  any 
abnormal  growths  in  or  about  the  uterus.  After  a  little  experience  the 
examiner  unconsciously  notes  these  different  facts  without  thought  of 
order  or  detail  of  method. 

It  is  well  to  bear  in  mind  that  during  the  early  months  of  pregnancy 
the  uterus  is  more  irritable  at  the  times  which  correspond  to  the 
menstrual  periods  and  at  these  times  even  a  bimanual  examination  may 
tend  to  induce  a  miscarriage.  In  making  a  bimanual  examination  then, 
the  would-be  menstrual  periods  should  be  avoided.  The  tendency  of  an 
uncorrected  retroversion  to  produce  a   miscarriage  is  so  great  that  as 


VAGINAL  AND  BIMANUAL  EXAMINATION  185 

soon  as  it  can  be  done  the  uterus  should  be  replaced  and  supported  by  a 
pessary  until  the  pregnancy  is  three  or  four  months  advanced.  This 
replacement  is  usually  easily  accomplished  by  placing  the  patient  on  her 
side  with  knees  drawn  up  (Sims's  position)  or  in  the  knee-chest  position, 
and  then  with  the  fingers  in  the  posterior  fornix  pushing  upward  gently 
on  the  fundus,  then  as  it  rises  transferring  the  fingers  to  the  front  of  the 
cervix  and  pushing  upward  and  backward  on  the  cervix.  In  some  cases 
where  the  retroverted  uterus  has  been  fixed  in  that  position  by  adhesions, 
the  uterus  cannot  be  replaced  at  once  and  time  must  be  given  for  nature 
to  soften  and  stretch  the  adhesions  in  the  growth  of  the  uterus.  The 
frequency  with  which  a  retroverted  pregnant  uterus  has  to  be  corrected 
at  the  time  of  the  preliminary  examination  is  so  great  that  it  has  seemed 
wise  to  include  a  brief  statement  here  concerning  it. 

Having  determined  the  condition  of  the  pelvic  organs  the  next  step 
is  the  examination  of  the  pelvic  canal. 


Fig.  133. — Mensuration  of  the  diagonal  conjugate. 

The  diameter  which  is  most  often  shortened  and  the  one  most  impor- 
tant to  know  is  the  true  conjugate,  i.  e.,  the  distance  between  the  promon- 
tory of  the  sacrum  and  the  upper  border  of  the  symphysis  pubis.  On 
account  of  the  difficulty  of  measuring  this  diameter  by  instruments 
devised  for  this  purpose  the  ordinary  method  employed  is  to  measure 
with  the  fingers  the  diagonal  conjugate  which  is  the  distance  from  the 
promontory  of  the  sacrum  to  the  lower  border  of  the  symphysis  pubis, 
this  giving  one  side  of  a  triangle  of  which  the  true  conjugate,  the  side 
desired,  and  the  height  of  the  symphysis  form  the  other  two.  By 
deducting  H-2  cm.,  depending  on  the  height  and  inclination  of  the 
symphysis  pubis,  from  the  length  of  the  diagonal  conjugate,  an  approxi- 
mation to  the  true  conjugate  is  obtained.  For  this  method  we  are  largely 
indebted  to  Baudelocque,  whose  name  is  also  associated  with  the  measure- 
ment of  the  external  conjugate  diameter.     To  measure  the  diagonal 


186  TtiE  MANAGEMENT  OF  NOUMAL  PREGNANCY 

conjugate  the  patient  is  placed  in  the  dorsal  position  with  knees  flexed, 
and  the  examiner  introduces  the  middle  and  index-fingers  of  his  left 
hand  (see  Fig.  133)  until  his  middle  finger  impinges  upon  the  promontory 
of  the  sacrum. 

In  order  to  reach  this  in  the  normal  pelvis  it  is  usually  necessary  to 
flex  well  the  ring  and  little  fingers,  to  depress  the  elbow  and  slightly  invert 
the  perineum  and  vulva.  On  reaching  the  promontory  the  radial  side 
of  the  hand  is  raised  firmly  against  the  subpubic  arch  and  with  the  index- 
finger  nail  of  the  right  hand  a  mark  is  made  on  the  left  index-finger  as 
near  the  lower  border  of  the  symphysis  as  possible.  The  examining  fingers 
are  then  withdrawn  and  an  assistant  measures  with 'a  pelvimeter  the 
distance  between  the  mark  on  the  left  index-finger  and  the  tip  of  the 
middle  finger.  This  is  the  diagonal  conjugate.  While  the  fingers  are 
in  the  vagina  feeling  for  the  promontor\'  they  should  be  swept  up  and 
down  the  posterior  and  lateral  walls  of  the  pelvis  noting  the  vertical  and 
lateral  curves  of  the  sacrum,  the  condition  of  the  coccyx,  and  the  amount 
of  room  at  the  sides  of  the  pelvis. 

The  promontory  of  the  sacrum  in  pelves  where  the  posterior  wall  can 
be  palpated  is,  as  a  rule,  easily  made  out  as  the  bony  margin  at  the 
base  of  the  sacrum.  In  some  cases,  however,  the  junction  of  the  first 
and  second  sacral  vertebrae  may  form  a  prominence  called  a  double 
promontory,  or  the  projection  of  the  last  lumbar  vertebra  may  cause 
confusion,  but  the  mention  and  thought  of  these  possibilities  will  usually 
enable  the  operator  to  avoid  the  error. 

The  amount  usually  deducted  from  the  diagonal  conjugate  to  obtain  the 
true  conjugate  is  1^  cm.,  but  this  presupposes  a  normal  height  of  the  sym- 
physis, about  4  cm. ;  a  normal  angle  between  symphysis  and  true  conjugate, 
about  105°;  a  normal  thickness  of  symphysis  and  a  normal  height  of  prom- 
ontory, but  unfortunately  for  pelvimetry  all  these  factors  are  subject  to 
variations.  In  practise  the  general  rule  is  to  deduct  1|  cm.,  if  the 
symphysis  seems  normal,  and  2  cm.  if  it  seems  higher  or  more  inclined 
than  normal. 

Numerous  instruments  have  been  devised  for  the  measurement  of  the 
true  conjugate,  notably  those  of  Stein,  Skutsch  and  Farabeuf,  but 
although  ingenious  and  theoretically  .accurate,  most  of  them  have  the 
disadvantage  of  being  cumbersome,  difficult  to  introduce  and  so  painful 
to  the  patient  as  often  to  require  anesthesia.  For  these  reasons  they 
are  very  little  employed.  P'urthermore,  Farabeuf's  instrument,  the 
anterior  bar  of  which  is  passed  through  the  urethra  into  the  bladder,  is 
rather  apt  to  abraid  the  vesical  mucosa. 

i\lore  recently  Hirst  has  devised  a  simpler  instrument  (see  Fig.  134), 
which  promises  to  be  of  marked  value.  The  following  illustrations  and 
description  of  the  use  of  his  instrument  are  taken  from  Hirst's  Text- 
hook  of  Obstetrics.  "The  patient  is  put  in  the  dorsal  position  with  the 
buttocks  projecting  beyond  the  edge  of  the  table  or  bed  on  which  she 
lies.  A  mark  with  the  point  of  a  lead-pencil  is  made  on  the  skin  over 
the  symphysis  pubis  about  |  inch  below  the  upper  edge.  The  two 
fingers  of  the  left  hand  are  inserted  in  the  vagina  as  in  measuring  the 


VAGINAL  AND  BIMANUAL  EXAMINATION 


187 


diagonal  conjugate.  The  tip  of  the  middle  finger,  having  found  the 
middle  line  of  the  promontory,  is  moved  a  little  to  the  patient's  right 
and  tip  B  of  the  pelvimeter,  shown  in  Fig.  1.34,  is  made  to  take  its  place. 
While  the  examining  physician  holds  the  shaft  of  the  pelvimeter  firmly 
in  place  the  assistant  adjusts  tip  A  of  the  movable  bar  over  the  mark 
made  on  the  sjTnphysis. 

"This  bar  is  then  screwed  tight,  the  whole  pelvimeter  is  removed  and 
the  distance  between  the  tips  is  found  by  a  tape-measure.  This  distance 
is  the  conjugate  plus  the  thickness  of  the  s^Tnphysis  (see  Fig.  135). 
The  thickness  of  the  s}Tnphysis  is  measured  as  shown  in  Fig.  136.  In 
living  subjects  the  index-finger  of  the  left  hand  must  find  the  inner 
surface  of  the  symphysis  pubis  and  must  follow  it  up  to  within  about 
I  inch  of  the  top  where  it  bulges  to  its  full  thickness.  On  this  point 
one  tip  of  the  pelvimeter  is  placed  and  it  is  then  held  in  position  between 
the  ends  of  the  first  and  second  fingers,  the  other  tip  of  the  instrument 


Fig.  134. — Hirst's  peh-imeter. 

is  adjusted  over  the  mark  made  on  the  skin  externally;  the  distance  is 
read  off  from  the  indicator  provided  for  the  purpose.  It  is  not  necessary 
to  make  an  allowance  for  the  thickness  of  the  tissues  over  the  symphysis, 
for  this  is  included  in  both  measurements,  and  on  subtracting  one  from 
the  other  the  necessary  correction  is  made.  The  tissues  over  the  inner 
surface  of  the  sjTQphysis  can  usually  be  so  compressed  by  the  knob  of  the 
pelvimeter  as  to  be  practically  eliminated.  If  this  is  impossible,  as  may 
happen  in  some  primigravidse,  a  small  allowance  may  be  made  for  these 
tissues,  say,  at  the  most  0.5  centimeter.  Even  with  this  pelvimeter 
anesthesia  is  sometimes  necessary,  yet  this  is  of  small  moment  when 
an  accurate  measurement  of  the  conjugate  is  needed." 

With  all  these  methods  for  measuring  the  true  conjugate  it  must  be 
remembered  that  the  other  factor  in  the  problem,  i.  e.,  the  fetal  head  is 
exceedingly  difficult  to  measure  and  that  the  real  problem  is  whether 
that  individual  head  will  pass  through  the  pelvis  in  question,  and  this 
cannot  be  determined  by  pure  mathematics.     For  these  reasons  the 


188  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

method  already  described  of  measuring  tlie  diagonal  conjugate  with  the 
fingers  and  then  deducting  a  certain  amount  to  obtain  the  true  conjugate 
is  the  method  most  generally  useful.  A  sufficient  knowledge  of  the 
transverse  diameter  of  the  cavity  of  the  pelvis  is  usually  obtained  by 


Fig.   135. — Measuring  the  true  conjugate,  plus  the  thickness  of  the  symphysis,  with 
Hirst's  pelvimeter.      (Hirst). 

careful  palpation  of  the  lateral  pelvic  wall  combined  with  consideration 
of  the  interspinous,  intercristal  and  oblique  diameters  obtained  by  exter- 
nal pelvimetry. 

So  little  is  gained  by  measuring  the  distance  between  the  trochanters 
that  this  procedure  is  omitted  in  routine  pelvimetry  at  the  Sloane 
Hospital. 


Fig.  136. — Measuring  the  thickness  of  the  symphysis  with  Hirst's  pelvimeter.    (Hirst.) 

Although  the  sacropubic  or  anteroposterior  diameter  of  the  outlet  may 
be  measured  externally  with  a  pelvimeter,  a  very  good  method  is  by  the 
use  of  the  vaginal  fingers  in  a  manner  similar  to  the  method  used  in 
measuring  the  diagonal  conjugate.     In  this  case  feeling  with  the  second 


CEPHALOMETRY  189 

finger  of  the  left  hand  the  apex  of  the  sacrum,  the  radial  side  of  the  index- 
finger  is  marked  with  the  index-finger  nail  of  the  other  hand,  just  beneath 
the  pubic  arch.  The  distance  between  this  mark  and  the  tip  of  the  middle 
finger  is  then  measured  with  a  pelvimeter.  This  gives  the  approximate 
length  of  the  sacropubic  diameter. 

A  very  valuable  internal  pelvimeter  in  all  practical  obstetrics  is  the 
individual  hand  of  the  obstetrician,  as  has  been  well  emphasized  by 
Edgar  in  his  text-book.  If  the  obstetrician  knows  the  transverse  diam- 
eter of  his  flat  hand  and  of  his  closed  fist  and  the  size  of  the  latter  as 
compared  to  a  normal  fetal  head,  he  can  often,  with  the  patient  under 
anesthesia,  and  hand  in  the  vagina,  tell  better  whether  a  fetal  head  will 
pass  than  by  any  metal  pelvimeter. 

Cephalometry. — If  the  examination  of  the  patient  is  at  or  near  term 
and  the  problem  is  presented  of  whether  the  given  head  will  pass  the 
individual  pelvis,  after  estimating  the  size  of  the  pelvic  canal  as  nearly 
as  possible,  it  is  desirable  to  know  the  size  of  the  child's  head. 

Various  methods  have  been  devised  for  determining  the  biparietal 
diameter  which  is  the  one  of  chief  consideration  in  the  passage  of  the 
head  through  a  contracted  pelvis.  The  first  to  practise  direct  measure- 
ment of  the  fetal  head  through  the  abdominal  wall  was  Ferret,^  who 
had  found  from  numerous  measurements  of  fetal  skulls  that  the  biparietal 
diameter  is  approximately  2|  cm.  shorter  than  the  occipitofrontal 
measurement.  For  measuring  the  occipitofrontal  diameter  through 
the  abdominal  wall  Ferret  devised  a  special  cephalometer,  the  tips 
of  which  are  applied  to  the  occiput  and  forehead  of  the  child  through 
the  abdominal  wall,  after  the  head  has  been  located  by  the  hands 
of  the  examiner,  and  the  reading  taken  from  the  scale  of  the  instru- 
ment. The  thickness  of  the  abdominal  wall  is  then  measured  by  pinch- 
ing up  a  fold  of  it  and  measuring  this  with  the  cephalometer  or  a  pel- 
vimeter. Subtracting  this  measurement  from  the  previous  one  gives  the 
occipitofrontal  diameter  of  the  child's  head.  If  2^  cm.  is  now  subtracted 
from  this  we  obtain  the  biparietal  diameter,  the  measurement  desired. 

In  the  hands  of  Ferret  the  results  were  surprisingly  good,  and  the 
difference  between  the  antepartum  and  postpartum  measurement  remark- 
ably small. 

In  1915  Stone^  published  a  modification  of  Ferret's  method  in  which 
an  ordinary  pelvimeter  is  used  and  no  deduction  made  for  the  thickness 
of  the  abdominal  wall.  Neither  the  Ferret  method  nor  that  of  Stone 
is  applicable  when  the  head  is  engaged,  but  when  not  engaged  the  head 
can  be  measured  by  the  Stone  method  as  follows: 

With  the  patient  in  the  ordinary  dorsal  position,  the  examiner  stands 
facing  the  foot  of  the  table  and  carefully  maps  out  the  position  of  the 
fetal  head,  grasping  the  occipital  and  frontal  poles  between  the  fingers 
of  the  two  hands.  An  assistant  facing  the  examiner  then  places  the  tips 
of  the  pelvimeter  firmly  on  the  fetal  head  between  the  ends  of  the  middle 
and  ring  fingers  of  the  examiner,  who  directs  the  location  and  amount 

iLa  cephalometrie  externe,  etc.,  L'Obstetrique,  1899,  iv,  542-584. 
2  New  York  Med.  Record,  November  4,  1905,  p.  725. 


190  THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

of  pressure.  From  this  occipitofrontal  diameter  is  subtracted  2.5  cm., 
which  is  the  average  difference  between  the  occipitofrontal  and  biparietal 
diameters  at  the  seventh,  eighth,  and  ninth  month  of  pregnancy. 

Stone,  after  further  experience  with  the  method,  recommends  that 
with  heads  ha^'ing  an  occipitofrontal  diameter  of  less  than  11  cm.,  2 
cm.  be  subtracted,  and  where  the  occipitofrontal  diameter  is  more  than 
11  cm.,  2.5  cm.  be  subtracted. 

Manual  Methods. — In  addition  to  the  instrumental  methods  of  meas- 
uring the  fetal  head,  various  manual  procedures  for  estimating  the  relati\'e 
size  of  the  head  and  pelvic  canal,  the  real  problem  of  importance,  are  in  use. 

In  the  method  introduced  by  Miiller,  and  often  called  by  his  name, 
the  brow  and  occiput  of  the  fetus  are  seized  by  the  fingers  of  the  two 
hands  through  the  abdomen  and  downward  pressure  made  upon  the 
head  in  the  axis  of  the  superior  strait,  while  an  assistant  with  fingers  in 
the  vagina  notes  the  amount  of  engagement  and  descent.  In  a  modifi- 
cation of  this  method  practised  by  Pinard,  of  Paris,  and  called  by  him 
"Le  palper  mensurateur,"  no  assistant  is  necessary,  but  after  the  fetal 
head  has  been  placed  in  the  brim  of  the  pelvis  by  the  fingers  of  both 
hands  working  through  the  abdomen,  with  one  hand  externally,  the  head 
is  pushed  downward  and  backward  so  that  its  posterior  surface  lies 
against  the  promontory,  while  the  obstetrician  with  the  fingers  of  the 
other  hand  in  the  vagina  tries  to  insert  them  between  the  head  and  the 
symphysis  and  in  this  way  determine  the  amoimt  of  additional  room. 

The  method  which  has  given  the  author  most  satisfaction  might  be 
called  a  combination  of  the  two  above  mentioned  and  consists  of  two  steps: 

1.  Abdominal  Manipulation. — With  the  fingers  of  both  hands  on  the 
long  diameter  of  the  head  (as  in  Fig.  130),  for  palpation  of  the  lower 
fetal  pole)  endeavor  to  engage  the  head  in  the  brim  of  the  pelvis  and 
note  the  extent  this  is  possible. 

2.  Bimanual  Manipulation. — With  the  fingers  of  one  hand  in  the  vagina 
and  the  other  hand  on  the  abdomen  determine  first  by  pressure  on  the 
head  above  the  symphysis  and  then  by  downward  pressure  on  the  fundus 
of  the  uterus,  the  ease  with  which  the  head  is  made  to  engage  and  the 
amount  of  descent  as  felt  by  the  vaginal  fingers.  In  all  these  manipula- 
tions, if  the  patient  is  very  sensitive  or  the  abdominal  wall  very  thick 
it  may  be  necessary  for  a  satisfactory  examination  to  place  the  woman 
under  an  anesthetic. 

A  method  which  is  often  of  ^'alue  when  the  patient  is  anesthetized  con- 
sists in  the  insertion  of  the  whole  hand  into  the  vagina,  seizing  and  palpating 
the  fetal  head  for  determination  of  its  size,  then  closing  the  hand  and  com- 
paring the  size  of  the  fist  with  the  different  diameters  of  the  pelvis. 

Of  course  the  methods  above  described  are  ina])plicab]e  in  any  save 
cephalic  ])resentations  and  are  usually  inapplicable  in  cases  of  placenta 
previa  except  those  of  the  extreme  lateral  type.  In  these  manual  proced- 
ures, if  the  head  can  readily  be  made  to  dip  into  the  pelvis,  a  favorable 
prognosis  of  normal  labor  is  easily  justified,  while  on  the  contrary  the 
converse  is  not  always  true  as  the  capacity  of  the  head  for  molding 
under  the  influence  of  labor  is  always  uncertain. 


CHAPTER  VI. 
MULTIPLE  PREGNANCY. 

A  MULTIPLE  pregnancy  (not  including  ectopic  gestation)  is  one  in 
which  the  gravid  uterus  contains  more  than  one  fetus.  It  is  called  a 
twin,  triplet,  quadruplet,  quintuplet,  or  sextuplet  pregnancy,  according 
to  the  number  present.  There  are  only  a  few  sextuplet  pregnancies  on 
record,  and  some  of  these  the  author  by  investigation  has  found  to  be 
spurious. 

Frequency. — Some  idea  of  the  frequency  of  multiple  pregnancy  may 
be  gained  by  a  study  of  the  20,000  consecutive  deliveries  at  the  Sloane 
Hospital.  In  this  series  there  were  244  pairs  of  twins  and  4  sets  of  trip- 
lets. In  a  series  of  33,000  consecutive  deliveries  at  this  hospital  there 
have  occurred  no  quadruplets,  quintuplets,  or  sextuplets. 

Etiology. — ^Little  is  known  concerning  the  etiology  of  multiple  preg- 
nancy, save  that  heredity  plays  a  very  important  part.  This  is  seen 
especially  on  the  maternal  side,  and  cases  are  on  record  in  which  multiple 
pregnancy  has  occurred  in  all  the  females  of  the  family  for  several 
generations. 

The  hereditary  influence  favoring  multiple  pregnancy,  although  usually 
most  marked  on  the  maternal  side,  is  not  confined  to  it,  as  occasionally 
the  influence  is  seen  to  be  paternal,  as  is  shown  by  marriage  to  different 
wives  being  followed  by  multiple  pregnancy.  According  to  Hellin^  the 
ovaries  of  women  who  have  had  a  number  of  multiple  pregnancies  con- 
tain a  greater  number  of  ova  than  is  usual  and  the  frequency  of  multiple 
pregnancy  is  probably  due  to  the  ripening  each  month  of  several  ova 
instead  of  one. 

Multiple  pregnancy  seems  to  be  much  more  common  in  some  countries 
than  in  others.  Thus,  reports  seem  to  indicate  that  they  are  especially 
common  in  Russia  and  in  Greece. 

Multiple  pregnancy  is  more  common  in  multigravidse  than  in  primi- 
gravidse.  In  the  series  of  244  twin  pregnancies  at  the  Sloane  Hospital 
there  were  140,  or  57.4  per  cent,  multigravidee  and  only  104,  or  42.6  per 
cent,  primigravidse.  In  the  4  sets  of  triplets  3  were  in  multigravidse 
and  only  1  in  a  primigravida. 

Twin  Pregnancy. — As  seen  from  the  statistics  of  the  Sloane  Hospital, 
twin  pregnancy  is  by  far  the  most  common  form  of  multiple  pregnancy. 
The  frequency  of  244  in  20,000  dehveries  gives  a  percentage  of  1.22 
per  cent.,  or  about  1  in  82. 

Twin  pregnancy  may  result  from  the  fertihzation  of  two  ova  from  the 
same  or  from  difterent  ovaries,  or  it  may  residt  from  the  fertilization  of 
one  ovum  which  has  two  nuclei  (see  Fig.  137),  each  nucleus  being  fer- 

1  Die  Ursache  der  Multiparitat  der  uniparen  Thiere,  etc.,  Miinchen,  189.5. 

(191) 


192 


M ULTIPLE  rREGXAXCY 


Fig.  137. — Ovum  with  two  nuclei 
(Bumm,  after  v.  Franque). 


tilized.     Single  ovum  twin.s  may  also  arise,  as  is  believed  today,  by  a 

division  of  the  blastodermic  vesicle  somewhat  resembling   the  process 

followed  in  the  formation  of  double 
monsters.  Twins  arising  from  a 
single  ovum  are  always  of  the  same 
sex.  Twins  from  separate  ova  may 
be  of  the  same  or  of  the  opposite 
>ex.  Twins  of  course  usually  de- 
\elop  in  the  same  uterine  ca\'ity. 
Twins,  however,  which  arise  from 
two  ova  may  each  develop  in 
separate  halves  of  a  double  uterus 
or  one  may  develop  in  the  uter- 
ine cavity  and  one  in  the  Fallo- 
pian tube. 
Superfecundation   and   Superfetation. — In   the   ordinary  type   of    twin 

pregnancy  the  two  ova  are  supposed  to  be  fertilized  as  the  result  of  a 

single  coitus.     The  term  superfecundatioyi,  however,  is  used  to  explain 

the  fertilization  of  two  ova  within 

a  short  period  of  each  other,  but  not 

at   the  same   intercourse.     Superfe- 
cundation undoubtedly  occurs  in  the 

lower    animals    and    its   occurrence 

among  human  beings  has  been  de- 

monstraterl  quite  a  number  of  times 

where  two  men   of  different  color, 

race    or   distinctive    characteristics 

have  had  intercourse  with  the  same 

woman  with  a  short  period  of  time 

between  them  and  the  children  have 

shown    the    characteristics    of    the 

different  fathers. 

Superfetation  implies  the  presence 

in  the  uterus  of  a  fetus  of  several 

weeks,  or  months,  development   at 

the  time  of  the  fertilization  of  the 

second   ovum.    While  theoretically 

this  is  possible  until  the  decidua  cap- 

sularis  reaches  the  decidua  parietalis 

which  lies  opposite  to  it,  its  occur- 
rence has  been  accepted  with  a  good 

deal  of  scepticism  and  its  positive 

existence  is  difficult  to  prove.    The 

term   superfetation  was  introduced 

to  explain  the  marked  difference  in 

development  found  in  the  two  fetuses 

at  term  and  yet  there  are  numerous  cases  in  which  one  twin  has  api)ro- 

priated  a  much  larger  part  of  the  space  and  nourishment  than  the  other. 


Fir,.  1.3S. — Fetus  papyraceus. 


TWIN  PREGNANCY 


193 


seen  in  its  extreme  degree  in  the  fetus  papyraceus  (see  Fig.  138)  in  which 
one  twin  has  been  killed  and  flattened  out  against  the  wall  of  the  uterus, 


Fig.  1.39. — Twin  pregnancy  from  separate  ova.    Placentae  separate. 


Fig.  140. — Twin  placentae  separate. 


the  other  twin  appropriating  all  the  nourishment.     Lesser  degrees  of 
inequality  of  nourishment  give  rise  to  fetuses  of  markedly    unequal 
13 


194 


MULTIPLE  PREGNANCY 


development.  If  the  smaller  fetus  is  retained  in  the  uterus  for  a  consider- 
able time  after  the  birth  of  the  first  and  only  then  gives  evidence  of  the 
development  usually  found  at  term  it  is  only  natural  that  the  explana- 


FiG.  141. — Twin  pregnancy  from  separate  ova.    Placentae  fused. 


Fig.  142. — Twin  placentae  fused. 


tion  of  superfetation  should  haxe  been  offered.  While  very  rarely  this 
explanation  may  be  the  correct  one,  it  must  be  extremely  exceptional 
and  the  explanation  of  unequal  nourishment  and  space,  or  the  presence 


TWIN  PREGNANCY 


195 


of  two  fetuses  in  different  halves  of  a  double  uterus,  more  commonly  the 
true  one. 

Arrangement  of  Placentae  and  Membranes. — Twins  arising  from  the  fer- 
tilization of  two  separate  ova  have  each  a  separate  amnion  and  a  separate 
chorion,  although  the  placentae  may  be  separate,  as  shown  in  Figs.  139 
and  140,  or  fused,  as  shown  in  Figs.  141  and  142. 

Twins  arising  from  the  fertilization  of  a  single  ovum  with  two  nuclei 
have  each  a  separate  amnion,  but  a  common  chorion  (see  Fig.  143). 
In  rare  cases  the  amniotic  partition  which  originally  existed  between 
the  twins  becomes  perforated  so  that  they  lie  in  a  common  amniotic 
sac.  If  the  ova  are  imbedded  in  the  decidua  at  sufficiently  distant  points 
(see  Fig.  144)  each  ovum  will  have  its  own  decidua  capsularis  (reflexa). 
If  the  embedding  areas  of  the  two  ova  are  near  each  other,  or  the  case 


Fig.  143. — Twins  from  a  single 
ovum . 


Fig.  144. — Twins  with  separate  decidua 
capsularis. 


is  one  of  single  ovum  twins  with  fused  placentae,  there  is  only  one  decidua 
capularis  (see  Fig.  143). 

In  twins  arising  from  a  single  ovum  there  is  more  or  less  anastomosis 
in  the  placenta  of  the  vascular  systems  of  the  two  fetuses.  This  may 
lead  to  unfortunate  results  in  several  ways.  One  fetal  heart  may  be 
stronger  than  the  other  and  appropriate  the  larger  portion  of  the  placenta 
and  blood.  The  stronger  heart  steadily  hypertrophies  while  the  weaker 
heart  atrophies,  even  to  the  extent  of  causing  the  deformity  called 
"  acardia."  The  stronger  heart  often  causes  a  hypertrophy  of  the  kidneys 
of  the  larger  fetus  with  an  accompanying  hydramnios. 

The  anastomosis  of  the  two  fetal  circulations  in  twin  pregnancy  from 
a  single  ovum  explains  the  necessity  of  ligating  twice  before  cutting 
the  cord  in  any  case  of  suspected  twins  lest  the  second  fetus  should 
bleed  to  death  from  the  untied  end  of  the  first  cord. 


196  MULTIPLE  PREGNANCY 

Presentations. — As  a  rule  the  long  axis  of  twins  corresponds  with  that 
of  the  mother.  Thus,  in  the  author's  series  of  244  cases,  207  were  longi- 
tudinal presentations,  while  37  were  more  or  less  transverse. 

Among  longitudinal  presentations  there  is  quite  a  variety.  In  the 
207  longitudinal  presentations  of  this  series,  there  were  98  in  which  the 
twins  both  presented  by  the  vertex;  90  in  which  one  presented  by  the 
vertex  and  the  other  by  the  breech;  and  19  in  which  both  presented  by 
the  breech.  In  longitudinal  presentations  the  twins  may  be  located  one 
on  each  side  of  the  mother's  abdomen  or  one  twin  may  lie  behind  the 
other.  In  transverse  presentations,  one  twin  may  lie  above  the  other 
or  one  behind  the  other.  It  is  readily  seen  that  when  one  twin  lies  behind 
the  other  it  may  be  difficult  to  detect  two  fetal  hearts. 

Sex  of  Twins. — As  already  stated,  twins  arising  from  the  fertilization 
of  a  single  ovum  with  double  nuclei  are  always  of  the  same  sex.  Twins 
arising  from  the  fertilization  of  two  separate  ova  may  be  of  the  same  or 
of  opposite  sex.  In  the  244  sets  of  twins  in  the  author's  series  the  sex 
was  as  follows: 

Male  and  female 98 

Both  females 74 

Both  males 69 

Sex  not  stated  in  history 3 

244 

Diagnosis. — The  diagnosis  of  twin  pregnancy  can  usually  be  made  if 
the  three  methods  of  inspection,  palpation  and  auscultation  are  carefully 
employed. 

Inspection. — The  shape  of  the  abdomen  is  usually  broader  from  side 
to  side  in  a  twin  pregnancy  than  in  cases  with  a  single  fetus.  Moreover, 
a  sulcus  can  sometimes  be  seen  marking  the  partition  between  the  two 
fetal  sacs.  The  excessive  size  of  the  abdomen  and  uterus  naturally  sug- 
gests the  presence  of  a  twin  pregnancy,  but  this  suggestion  is  chiefly 
of  value  in  causing  the  employment  of  careful  methods  of  palpation 
and  auscultation.  Enough  has  been  said  to  call  attention  to  the  fact 
that  while  the  results  of  inspection  are  chiefly  suggestions,  they  are  of 
value  as  leading  often  to  the  correct  diagnosis. 

Palpation. — The  feeling  of  two  fetal  heads  and  a  breech,  or  two  breeches 
and  a  head,  usually  enables  the  making  of  at  least  a  probable  diagnosis 
of  twin  pregnancy.  It  should  not  be  forgotten,  however,  that  certain 
tumors,  especially  fibroid  tumors  of  the  uterus  often  resemble  closely  a 
fetal  head  and  maA'  lead  to  an  error  in  diagnosis. 

Auscultation. — Of  all  the  methods  employed  in  making  the  diagnosis 
of  twin  pregnancy,  auscultation  is  the  one  most  to  be  depended  upon. 
Even  the  diagnosis  made  by  palpation  usually  has  to  be  verified  by  auscul- 
tation. Two  fetal  heart  sounds  synchronous  neither  with  each  other  nor 
with  the  mother's  pulse  is  the  criterion  of  twin  pregnancy.  No  matter 
how  suggestive  the  evidence  derived  from  inspection  and  palpation  may 
be,  the  obstetrician  should  seldom  commit  himself  to  a  positive  diagnosis 
of  twin  pregnancy  unless  two  fetal  hearts  can  be  heard, 


TWIN  PREGNANCY  197 

Course. — On  account  of  the  greater  distention  of  the  uterus  in  twin 
than  in  single  pregnancy  the  mother  is  more  apt  to  suffer  from  mechan- 
ical embarrassment  of  the  circulation  and  respiration.  Furthermore, 
the  increase  in  the  size  of  the  uterus  naturally  caused  by  the  presence  of 
twins  may  be  still  further  augmented  by  the  condition  of  hydramnios 
in  at  least  one  sac.  From  the  fact  that  oxygenation  and  elimination  are 
required  for  three  individuals  instead  of  two,  toxemia  is  more  common 
in  twin  than  in  single  pregnancy. 


Fig.  145. — Interlocking  twins,  both  heads  presenting. 

As  the  uterus  seems  to  endure  only  a  certain  amount  of  distention, 
this  limit  appears  to  be  reached  earlier  in  twin  than  in  single  pregnancy; 
therefore  a  certain  amount  of  prematurity  is  to  be  expected.  In  the 
author's  series  of  244  cases  there  were  119,  or  48.8  per  cent.,  in  which 
labor  w^as  two  or  more  weeks  premature.  As  a  result  of  prematurity  and 
divided  nutrition,  twins  are  usually  smaller  and  less  well  developed  than 
is  the  child  of  a  single  pregnancy.  Moreover,  one  twin  is  frequently 
smaller  and  less  well  developed  than  is  the  other.  This  is  seen  in  its 
extreme  degree  in  fetus  papyraceus  already  described  (see  page  193). 

Labor  in  Twin  Pregnancy. — As  there  is  a  greater  distention  of  the  uterus 
in  twin  pregnancy,  the  uterine  contractions  are  often  less  efficient  and 
farther  apart  than  normal,  thus  prolonging  the  labor.    Furthermore,  as 


198 


MULTIPLE  PREGNANCY 


the  uterus  has  often  to  exert  its  expulsive  power  on  tlie  first  child  by 
acting  through  the  second,  its  action  is  frequently  more  or  less  handi- 
capped. Twin  labor  may  be  complicated  in  several  ways  as  by  inter- 
locking, hemorrhage,  etc. 

Interlocking. — As  twins  are  usually  each  smaller  than  the  fetus  of  a 
single  pregnancy  the  second  fetus  sometimes  enters  the  pelvis  while  it  is 
still  occupied  by  some  part  of  the  first,  thus  interfering  with  the  fiu-ther 
progress  of  the  first.  This  complication  is  spoken  of  as  interlochiiuj,  or 
collision.  Several  varieties  of  interlocking  are  possible,  but  the  two 
deserving  most  consideration  are  the  following: 


Fig.  146. — Interlocking  twins.     Breech  and  vertex  presentation. 


1.  Both  heads  present  and  enter  the  pelvis,  one  a  little  in  advance  of 
the  other,  the  second  head  becoming  impacted  in  the  neck  of  the  first 
(see  Fig.  145). 

2.  The  first  child  presents  by  the  breech  but  the  second  head  enters 
the  pelvis  before  the  first  head,  and  facing  each  other  the  fetuses  interlock 
chin  to  chin  (see  Fig.  146). 

Other  varieties  of  interlocking  are  worthy  of  mention :  The  first  child 
sometimes  presents  by  the  breech  and  its  occiput  interlocks  with  the 
occiput  of  the  second  child  which  has  entered  the  pelvis.  Again,  the  first 
child  sometimes  presents  transversely  and  the  second  child  sits  astride 
of  the  first,  the  feet  of  the  second  presenting  in  the  vagina. 


TWIN  PREGNANCY  199 

Hemorrhage. — Aside  from  the  mechanical  compHcations  of  twin  labors, 
hemorrhage  is  more  common  on  account  of  the  greater  distention  of  the 
uterus  and  lessened  contractile  power.  Moreover,  the  puerperium  is 
more  apt  to  be  complicated  by  the  toxemia  which  has  already  been  men- 
tioned as  more  common  in  twin  pregnancy  and  by  sepsis,  which  is  always 
predisposed  to  by  a  postpartum  hemorrhage  and  by  the  greater  manual 
interference  which  is  often  required  in  a  twin  labor. 

Management  of  Twin  Labor. — The  management  of  the  first  half  of  an 
uncomplicated  twin  labor  does  not  differ  from  that  of  an  ordinary  labor 
in  a  single  pregnancy.  In  fact,  many  cases  of  twin  pregnancy  are  not 
diagnosed  until  after  the  birth  of  the  first  child,  when  the  uterus  is  found 
too  large  to  contain  only  a  placenta.  The  author  teaches  the  advisabilitj' 
of  a  double  ligature  of  the  cord  in  every  delivery  so  that  the  ligature  of 
the  cord  in  a  twin  labor  would  not  differ  from  that  in  a  single  delivery, 
although  the  neglect  of  the  double  ligatm-e  in  a  twin  labor  might  result 
in  the  death  of  the  other  twin  if  they  were  from  a  single  ovum. 

After  the  birth  of  the  first  twin  the  presentation  and  position  of  the 
second  shoidd  be  carefully  determined  and  corrected  if  abnormal.  After 
waiting  from  one-quarter  to  one-half  hour  for  the  uterus  to  contract 
on  the  second  fetus  the  membranes  should  be  ruptured  if  necessary 
and  the  birth  of  the  second  child  favored.  On  account  of  the  distention 
and  lessened  tone  of  the  uterus,  the  fundus  of  the  uterus  should  be  held 
for  at  least  an  hour  after  the  birth  of  the  second  child  to  avoid  the  danger 
of  postpartum  hemorrhage.  Occasionally,  one  placenta  and  rarely  both 
placentse  are  expelled  soon  after  the  birth  of  the  first  child.  In  the  latter 
case  the  second  child  must  be  delivered  as  rapidly  as  the  soft  parts  of  the 
mother  will  permit. 

Management  of  Twin  Labor  Complicated  by  Interlocking. — If  there  is 
marked  delay  in  the  delivery  of  the  first  tT\-in,  some  form  of  interlocking 
should  be  suspected  and  under  anesthesia  the  hand  shoidd  be  passed 
into  the  uterus  and  the  exact  conditions  determined.  If  both  twins 
present  by  the  vertex  and  the  second  has  become  impacted  in  the  neck 
of  the  first  child  as  shown  in  Fig.  145,  an  attempt  should  be  made  to 
push  up  the  second  head  and  deliver  the  first  child  with  the  forceps. 
Occasionally,  the  best  procedure  is  to  deliver  the  second  head  past  the 
first,  always  remembering  that  craniotomy  on  one  child  in  the  hope  of 
saving  the  other  may  be  good  obstetrics. 

If  the  first  child  presents  by  the  breech  and  its  body  is  born  whUe 
its  chin  is  locked  with  the  chin  of  its  fellow  (see  Fig.  146)  an  attempt 
should  be  made  to  unlock  the  heads,  but  if  this  attempt  fails  it  is  usually 
wise  to  decapitate  the  first  child,  pushing  up  its  head,  and  then  to  dehver 
the  second  child,  finally  delivering  the  head  of  the  first.  The  reason  for 
the  ^dsdom  of  this  com-se  lies  in  the  fact  that  with  failure  of  the  attempt 
to  dislodge  the  second  child's  head,  the  life  of  the  first  child  usually 
ceases  during  the  endeavor  to  extract  the  second  past  it,  and  the  second 
child's  life  is  much  more  likely  to  be  saved  if  the  canal  is  cleared  of  the 
first  child. 

If  the  first  child  hes  transversely  and  the  second  child  sits  astride  with 


200 


MULTIPLE  PREGNANCY 


feet  in  the  vagina  the  best  procedure  is  usually  to  perform  version  and 
extraction  upon  the  first  child,  although  eacli  of  these  cases  presents 
a  problem  of  its  own  and  must  be  dealt  with  individually,  some  cases 
justifying  Cesarean  section  and  some  craniotomy'. 

Mortality. — The  maternal  mortality  in  twin  pregnancy  is  slightly  higher 
than  in  single  pregnancy  on  account  of  a  slightly  increased  tendency  to 
toxemia,  postpartum  hemorrhage  and  sepsis  as  has  already  been  men- 
tioned. In  addition  to  these  complications  there  should  be  borne  in 
mind  the  possible  rupture  of  the  uterus  in  an  attempted  version  in  the 
case  of  interlocking  twins  when  the  uterus  is  too  tonic  to  safely  allow  of 
this  procedure.  In  the  author's  series  of  244  twin  deliveries  there  was 
no  maternal  mortality. 


Fig.  147. — Single  ovum  triplet  placenta,  maternal  surface. 

Some  idea  of  the  fetal  mortality  in  twin  pregnancy  may  be  gained 
from  the  results  in  the  author's  series  of  244  cases.    In  this  series: 

Both  children  lived  in  146  cases,  or  59.8  per  cent. 

One  child  lived  in  44  cases,  or  18  per  cent. 

Neither  child  lived  in  54  cases,  or  22.1  per  cent.,  but  of  these  54  cases 
12  were  so  premature  as  to  be  non-viable. 

Triplet  Pregnancy. — Etiology. — ^The  same  effect  of  heredity  is  seen  in 
triplet  as  in  twin  pregnancy  and  many  women  having  triplets  will  give 
a  history  of  having  had  twin  births.  Triplet  pregnancy  is  more  common 
in  multigravidse  than  in  primigravida?.  In  the  author's  series  of  four 
sets  of  triplets  only  one  was  a  primigravida  while  three  were  multigravidte. 


TRIPLET  PREGNANCY 


201 


Sex. — ^The  sex  of  triplets  is  about  equally  distributed.     In  the  four 
sets  of  the  author's  series  the  sex  was  as  follows: 

In  one  set,  all  females. 

In  one  set,  all  males. 

In  one  set,  one  male  and  two  females. 

In  one  set,  two  males  and  one  female. 

Arrangement  of  Placentae  and  Membranes. — Triplets  may  all  come  from 

the  fertilization  of  a  single  ovum  and  the  three  placentae  be  fused  in  one 

as  is  shown  in  Figs.  147  and  148,  or  they  may  come  from  the  fertilization 

of  three  separate  ova  and  the  three  placenta  be  separate  (as  in  Fig.  149) . 


Fig.  148. — Single  ovum  triplet  placenta.     Fetal  surface. 


It  is  rather  more  common  to  find  two  placentae  fused  and  one  more  or 
less  separate  (as  in  Fig.  150),  this  arrangement  arising  from  the  fertiliza- 
tion of  one  double  and  one  single  ovum. 

Course. — ^The  discomforts  and  complications  mentioned  above  as 
being  possible  accompaniments  of  twin  pregnancy  are  exaggerated  and 
much  more  frequent  in  triplet  pregnancy.  In  fact,  a  woman  pregnant 
with  triplets  is  usually  in  the  later  months  the  subject  of  great  discom- 
fort. The  distention'  of  the  abdomen  is  so  great  that  she  suffers  wdth 
dyspnea  and  frequently  has  to  sleep  bolstered  up  in  bed.  Albuminuria 
and  other  evidences  of  toxemia  are  usually  present.  Hydramnios^  is 
common.     Three  of  the  four  cases  in  the  author's  series  suffered  with 


202 


MULTIPLE  PREGNANCY 


hydramnios  and  albuminuria.    Triplet  i)regnancy  seldom  goes  to  term. 
In  all  four  cases  ot"  the  ai)ove  series  tiie  labor  was  premature. 


Fig.  149. —  Triplet  placenta;  from  three  separate  ova.     Fetal  aurJace. 


Fig.  150. — Triplet  placentae,  two  fused  and  one  separate. 


TRIPLET  PREGXANCY  203 

Labor  in  Triplet  Pregnancy. — The  labor  in  triplet  pregnancr  is  seldom 
marked  by  dystocia,  as  the  children  are  all  small,  but  it  may  be  tedious 
on  account  of  the  excessive  distention  of  the  uterus  and  feeble  uterine 
contractions.  The  uterine  inertia  shows  itself  in  the  frequent  occur- 
rence of  postpartum  hemorrhage,  which  should  be  guarded  against  by 
carefully  holding  and  watching  the  fundus  of  the  uterus  after  the  delivery. 
The  birth  of  the  second  and  third  fetus  often  follows  the  first  after  a 
short  interval,  but  should  this  not  occur  within  half  an  hour,  it  is  usually 
wise  to  rupture  the  second  sac  and  expedite  the  delivery  of  the  other 
fetuses.    Each  cord  should  be  ligated  twice  before  cutting. 

Mortality. — The  maternal  mortality  is  always  somewhat  higher  than 
in  t-udn  pregnancy  on  account  of  the  greater  distention  of  the  uterus  and 
the  greater  tendency  to  toxemia,  postpartum  hemorrhage,  and  sepsis. 
The  fetal  mortality  is  always  high  on  account  of  prematurity  and  di\'ided 
nutrition.  In  the  foiu-  sets  of  triplets  in  the  author's  series  the  results 
were  as  follows: 

In  one  set  all  were  stillbirths,  too  premature  for  \ia1)ilit.\'. 

In  one  set  all  died  soon  after  birth. 

In  one  set  two  lived. 

In  one  set  all  three  lived  and  grew  up. 

There  was  no  maternal  mortality  in  this  series. 


CHAPTER  VII. 
NORMAL  LABOR. 

PHYSIOLOGY   OF   NORMAL  LABOR. 

Labor  is  the  process  by  which  the  product  of  conception  is  separated 
from  the  uterus  and  is  propelled  along  the  parturient  canal  to  the  outside 
world.  The  term  is  usually  applied  to  the  termination  of  a  gestation 
which  is  mature  or  nearly  so,  yet  the  process  may  be  strongly  resembled 
in  the  earlier  months  of  pregnancy.  Labor  is  either  normal  or  abnormal. 
A  normal  labor  is  one  in  which  there  is  a  vertex  presentation  and  the 
birth  is  accomplished  unaided  within  a  reasonable  time,  and  it  is  this 
normal  labor  which  will  here  be  considered.  One  of  the  questions  which 
constantly  presents  itself  is  that  of  the  suffering  of  labor.  Why  should 
nature,  which  usually  illustrates  so  admirably  the  adaptation  of  means 
to  an  end,  require  such  suffering  in  the  birth  of  the  human  race?  While 
this  question  cannot  be  answered  with  entire  satisfaction,  much  can  be 
learned  by  comparison  (1)  of  the  human  race  with  the  lower  animals, 
and  (2)  of  the  higher  classes  of  civilization  with  the  lower. 

Comparison  of  the  Human  Race  with  the  Lower  Animals. — That 
labor  in  women  is  more  difficult  than  in  the  lower  animals  is  readily 
understood  when  we  compare  the  pelvis  of  the  cow  (see  Fig.  151)  with 
that  of  the  human  female,  and  consider  that  in  women  the  pelvis  must 
be  suited  for  the  erect  posture.  In  the  lower  mammals,  not  assuming 
the  erect  posture  and  therefore  requiring  but  little  support  for  the  pelvic 
organs,  the  pelvic  cavity  shows  but  little  curve.  There  is  no  projecting 
promontory  to  prevent  engagement  of  the  head  and  the  symphysis  is 
lower.  This  allows  ready  entrance  at  the  brim  of  the  pelvis  and  as  the 
conjugate  is  longer  than  the  transverse  diameter  through  the  whole 
pelvic  canal,  there  is  not  the  need  for  the  rotation  of  the  fetal  head  that 
often  requires  so  much  time  and  suffering  in  the  human  female. 

The  caudal  extremity  of  the  spinal  column  is  easily  movable  so  that 
there  is  little  obstruction  at  the  outlet.  Furthermore,  in  the  lower  mam- 
mals the  pelvic  floor  possesses  much  less  resistance  than  in  the  human 
female,  and  during  pregnancy  the  ligaments  and  articulations  of  the 
pelvis  are  much  more  relaxed.  When  it  is  considered  that  the  fetal  head 
in  the  lower  mammals  is  relatix-ely  smaller  and  more  conical,  it  can 
readily  be  seen  why  labor  in  the  lower  mammals  is  less  difficult  than  in 
women.  Furthermore,  in  the  lower  mammals  the  nervous  system  is  at 
lower  tension  and  development,  and  less  easily  exhausted.  In  them  the 
mental  condition,  so  often  an  important  feature  in  women,  can  largely 
be  eliminated  from  the  problem. 
(204) 


PHYSIOLOGY  OF  NORMAL  LABOR 


205 


Comparison  of  Higher  Civilization  with  the  Lower. — The  fact  that 
labor  among  the  Indians,  when  Kving  their  normal  out-of-door  life  un- 
touched by  civilization,  was  a  simple  procedure,  is  well  known,  and  often 
referred  to  in  comparison  with  the  process  as  met  with  today.  Yet  in 
my  experience,  when  one  of  the  '^  modern,  civilized"  Indians,  so-called, 
presents  herself  at  the  maternity  hospital  her  labor  differs  but  little,  if 
any,  from  that  of  other  women  living  as  she  does. 

^Modern  civilization,  with  its  increased  mental  development,  greater 
nerve  strain  and  lessened  physical  de^'elopment,  adds  greatly  to  the 


Wing  of 
sacrum 


Median 

crest  of     Tuber 

sacrum     sacrale 


Acetabulum 
Tuber  ischii 


Ilio-pectineal  eminence 

Symphysis  pubis 


Obturator  foramen 


Ventral  ridge 
Fig.   151. — Pehdc  bones  of  cow,  ^■iewed  from  in  front  and  somewhat  from  below.     (Sisson.) 


difficulty  of  labor.  It  increases  the  mechanical  difficulties  of  the  problem 
by  increasing  [the  size  of  the  child's  head,  and  lessens  the  ability  to 
overcome  the  difficulties  by  lowering  nerve  and  muscle  tone. 

The  same  thing  is  seen  to  a  certain  extent  in  horses  and  cattle  where 
those  of  highest  breed  which  are  carefully  housed,  groomed  and  fed, 
surrounded  by  protection  from  wind  and  weather,  present  more  diffi- 
culty in  parturition  than  do  those  on  the  prairie. 

Cause  of  the  Onset  of  Labor. — ]\Iuch  speculation  has  been  indulged  in 
and  manv  theories  advanced  to  explain  why  labor  usually  begins  at 


206  NORMAL  LABOR 

about  two  hundred  and  eighty  days  from  the  beginning  of  the  last  men- 
struation. 

A  satisfactory  definite  answer  has  never  been  given.  It  is  probably 
the  result  of  a  number  of  conditions  no  one  of  which  can  singly  be  pointed 
to  as  the  cause  of  the  onset  of  labor.    The  following  may  be  mentioned: 

Placental  Changes. — During  the  latter  part  of  pregnancy  there  is 
taking  place  in  the  decidual  portion  of  the  placenta  a  form  of  degeneration 
which  is  preparing  it  for  separation;  in  other  words,  is  preparing  the 
product  of  gestation  to  become  like  a  foreign  body  in  the  uterus. 

It  is  well  known  that  a  foreign  body  in  the  uterus,  whether  it  be  a 
polypus,  a  blood-clot,  or  the  hand  of  the  obstetrician,  stimulates  uterine 
contractions,  and  this  condition,  present  in  the  latter  part  of  pregnancy, 
has  been  adopted  as  one  of  the  causes  of  the  onset  of  labor.  This  theory 
was  advanced  by  Naegele,  and  has  found  many  followers. 

Uterine  Distention. — On  account  of  the  frequency  with  which  pre- 
mature labor  occurs  in  multiple  pregnancy  and  hydramnios,  uterine 
distention  has  been  looked  upon  as  one  of  the  causes  of  the  onset  of 
labor  and  it  is  thought  that  when  the  uterus  reaches  a  certain  amount 
of  distention  it  will  try  to  empty  itself.  While  this  certainly  appears 
to  be  the  fact  in  most  cases,  numerous  exceptions  occur  as  when  preg- 
nancy is  prolonged  beyond  term  and  the  child  is  allowed  to  reach  an 
extreme  size  and  weight. 

Changes  in  the  Lower  Uterine  Segment. — The  softening,  dilatation  and 
retraction  of  the  lower  uterine  segment,  as  the  presenting  part  settles  in 
the  pelvis,  is  certainly  a  preparation  for  labor  and  in  the  same  way  that 
an,  elastic  bag  placed  in  the  cervical  canal  will  induce  labor,  so  the  pres- 
ence of  the  presenting  part  with  the  amniotic  sac  in  front  of  it,  gradually 
dilating  the  canal  and  pressing  upon  the  pelvic  nerves,  tends  to  start 
up  uterine  contractions.  This  view  finds  support  in  the  fact  that  occa- 
sionally, as  has  occurred  several  times  in  my  experience,  when  the  cervix 
has  previously  been  amputated  and  the  lower  uterine  segment  is  dilated 
during  most  of  the  latter  half  of  pregnancy,  it  is  extremely  difficult  to 
carry  the  patient  to  term.  In  one  patient,  after  several  premature  labors 
with  loss  of  the  child,  a  successful  issue  was  secured  only  by  keeping  the 
patient  in  bed.  The  fact  that  at  times  the  cervix  shows  marked  dilata- 
tion for  weeks  before  term  shows  that  this  is  not  the  sole  cause  of  the 
onset  of  labor. 

Increasing  Irritability  of  the  Uterus. — It  is  well  known  that  in  the 
latter  part  of  pregnancy  the  uterus  is  more  irritable,  i.  e.,  responds  more 
readily  to  stimulation  and  that  the  intermittent  uterine  contractions, 
the  so-called  Braxton  Hicks  sign  of  pregnancy,  although  present  from 
early  pregnancy,  become  more  pronounced  and  more  frequent  as  term 
approaches.  Furthermore,  although  usually  these  intermittent  uterine 
contractions  are  painless,  in  some  w^omen  they  are  painful  and  difficult 
to  distinguish  from  beginning  labor. 

Menstrual  Periodicity. — Tyler  Smith,  Mende  and  others  have  ad- 
\anced  the  view  that  labor  is  most  apt  to  occur  at  a  time  which  would 
be  the  menstrual  period  were  the  patient  not  pregnant,  i.  e.,  the  tenth 


PHYSIOLOGY  OF  NORMAL  LABOR  207 

menstrual  period.  This  tendency  of  the  uterus  to  contract  and  empty 
itself  at  the  would-be  menstrual  periods  certainly  seems,  to  exist  in  the 
early  months  as  is  evidenced  by  the  age  of  the  specimens  obtained  from 
miscarriages,  and  in  all  probability  exists  also  in  the  later  months  of 
pregnancy. 

Stimulation  of  the  Uterine  Nerve  Centres. — The  theory  has  been 
advanced  by  several,  especially  by  Brown-Sequard,  that  the  onset  of 
labor  is  caused  by  the  irritation  of  the  uterine  nerve  centres  by  an  excess 
of  carbon  dioxide  circulating  in  the  blood.  Although  this  theory  may 
prove  to  have  little  influence  upon  the  onset  of  labor,  it  is  suggestive  of 
work  along  the  line  of  determining  whether  some  other  substance  in  the 
circulation,  perhaps  some  product  of  fetal  metabolism,  may  not  be  a 
causal  factor. 

Exciting  Causes. — It  is  well  known  that  when  the  time  is  reached 
that  labor  is  really  due,  a  very  slight  exciting  cause  like  a  bimanual 
examination,  a  purgative,  violent  exercise,  etc.,  may  determine  the  onset 
of  labor. 

This  is  sometimes  made  use  of  clinically  by  giving  a  purgative  like  a 
large  dose  of  castor  oil  at  the  time  estimated  to  be  the  normal  end  of 
pregnancy  in  order  to  prevent  overgrowth  of  the  child  by  the  continua- 
tion of  pregnancy  beyond  term. 

The  above-mentioned  theories  are  those  which  have  been  most  widely 
held  and  are  most  worthy  of  acceptance  as  influential  factors.  If,  how- 
ever, we  frankly  ask  ourselves  the  question  "  What  is  the  real  cause  of  the 
onset  of  labor?"  we  are  forced  to  reply  "We  do  not  know."  As  the  apple 
when  fully  ripe  falls  from  the  tree,  so  the  fetus  when  it  is  best  suited 
for  independent  life  is,  as  a  rule,  expelled  from  the  uterus. 

The  Characteristics  of  Beginmng  Labor. — One  of  the  questions  fre- 
quently asked  by  the  patient  expecting  to  be  confined  is  "How  shall  I 
know  when  I  am  in  labor?"  The  question  is  a  perfectly  natural  one,  as 
it  is  not  unusual  for  women  to  have  various  aches  and  pains  during 
the  latter  part  of  pregnancy.  These  may  be  due  to  pressure  upon  the 
pelvic  nerves,  to  gas  in  the  intestines  whose  normal  peristaltic  action  is 
interfered  with  by  the  enlarging  pregnant  uterus;  finally,  as  already 
indicated,  the  intermittent  uterine  contractions  which  continue  during 
pregnancy  and  are  usually  painless,  in  some  women  are  painful  and 
resemble  the  pains  of  beginning  labor,  but  are  irregular  in  occurrence 
and  without  increasing  severity.  These  are  the  so-called  false  or 
spurious  labor  pains.  The  best  information  that  can  be  given  to  the 
patient  regarding  the  characteristics  of  true  labor  pains,  is  that  the  onset 
of  labor  is  marked  by  pains  which  recur  regularly  with  distinct  inter- 
missions; that  during  these  pains  the  abdomen  seems  hard;  that  these 
pains  are  located  at  first  either  in  the  abdomen  above  the  pubes,  or  in 
the  back  in  the  lumbosacral  region;  that  later  they  become  more  con- 
stant in  the  lumbosacral  region  and  extend  down  the  thighs;  that  often 
in  the  beginning  the  interval  between  pains  is  half  an  hour  or  more,  but 
as  time  goes  on  the  intervals  become  shorter  and  the  intensity  of  the 
pains  greater.     In  addition  to  this  there  is  usually  an  increase  in  the 


208  NOHMAL  LABOR 

vaginal  mucous  discharge,  which  may  or  may  not  be  colored,  producing 
what  the  laity  speak  of  as  a  "  show."  In  studying  labor  it  is  well  to  recog- 
nize a  'preparaiory  stage,  in  which  the  uterus  and  its  contents  settle  in 
the  pelvis,  thus  allowing  greater  freedom  of  action  to  the  diaphragm  and 
easier  respiration  to  the  patient,  but  greater  discomfort  below  from 
pressure  upon  the  pelvic  viscera,  vessels,  and  nerves.  There  is  more 
irritability  of  the  bladder  and  disturbance  with  the  rectum,  greater 
interference  with  venous  return,  as  shown  by  increased  edema  in  the 
lower  extremities  and  vulva,  and  more  pain  in  the  pelvis  radiating  down 
the  thighs. 

This  settling,  aside  from  being  felt  and  noticed  by  the  patient,  is  easily 
made  out  by  palpation  of  the  abdomen.  The  fundus  has  receded  from 
the  ensiform  cartilage,  returning  to  about  the  level  of  the  eighth  month 
and  on  palpating  the  fetal  head  it  is  found  to  have  dipped  into  the  pelvic 
brim.  The  settling  usually  begins  in  primigravidte  at  about  two  weeks 
from  term,  but  in  multigravidje  with  less  tone  in  the  abdominal  wall 
and  lower  uterine  wall  it  often  does  not  occur  until  the  last  week  of 
pregnancy. 

This  is  the  stage  during  which  the  irregular,  spurious,  or  false  pains 
occur,  as  already  described,  and  a  vaginal  examination  during  this  period 
shows  the  following  changes:  The  vulva  is  more  gaping  and  more  con- 
gested. The  cervix,  which  up  to  this  time  has  retained  its  normal  length, 
with  the  external  os  and  the  internal  os  both  present  and  more  or  less 
closed,  especially  in  primigravidtie,  shows  a  dilatation  and  a  gradual 
disappearance  of  the  internal  os  as  the  lower  uterine  segment  retracts. 


STAGES   OF  LABOR. 

In  the  actual  labor  three  stages  are  recognized: 

First  stage,  or  the  stage  of  dilatation,  which  extends  from  the  beginning 
of  labor  to  the  time  of  complete  dilatation  of  the  cervix. 

Second  stage,  or  tJie  stage  of  expulsion,  which  extends  from  the  complete 
dilatation  of  the  cervix  to  the  birth  of  the  child. 

Third  stage,  or  the  placental  stage,  which  extends  from  the  birth  of  the 
child  to  the  expulsion  of  the  placenta. 

Usually  these  three  stages  are  present  in  every  labor  and  a  normal 
labor  has  only  to  be  observed  to  see  the  three  follow  each  other  in  turn. 

Occasionally,  however,  especially  in  women  whose  nervous  systems 
are  at  high  tension  and  whose  cervices  are  rigid,  the  patient  becomes 
completely  exhausted  in  the  first  stage  and  in  spite  of  attempts  at  rest, 
she  is  unable  to  dilate  her  cervix  until  the  long  pressure  begins  to  have 
deleterious  effect  upon  the  fetal  heart. 

In  such  cases,  although  the  patient  may  have  had  expulsive  pains  and 
an  expulsive  stage,  she  has  had  no  second  stage,  according  to  the  defini- 
tion given  above,  as  she  requires  artificial  dilatation  of  her  cervix  and 
instrumental  delivery  before  she  herself  has  succeeded  in  dilating  the 
cervical  canal. 


STAGES  OF  LABOR  209 

First  Stage. — With  the  onset  of  labor  the  patient  begins  to  have 
the  true  labor  pains,  at  first  with  intervals  perhaps  of  half  an  hour,  but 
becoming  more  frequent  as  time  goes  on.  These  pains  are  usually  located 
in  the  sacral  region  and  often  radiate  to  the  lower  part  of  the  abdomen  or 
down  the  thighs.  At  first  the  patient  is  often  rejoiced  that  labor  which 
she  has  been  expecting  so  long  has  really  come  and  she  watches  carefully 
to  see  if  the  pains  recur  regularly  and  are  becoming  stronger  and  are  not 
the  irregular,  false  pains,  which  she  may  have  had  for  several  weeks. 
At  first  she  feels  very  comfortable  between  pains  and  chats  pleasantly 
as  she  watches  with  interest  the  preparations  of  the  bed  and  room. 
The  pains  of  the  first  stage,  however,  are  wearing  and  after  a  time  the 
patient,  especially  a  primigravida,  is  apt  to  become  restless  and  nervous 
and  asks  how  much  longer  the  labor  is  to  last.  She  thinks  she  is  not 
accomplishing  anything.  She  feels  her  abdomen  and  says  it  has  not 
gone  down  any.  The  pains  by  this  time  are  probably  sharp  and  she 
cries  out  as  they  recur.  As  the  cervix  dilates  she  is  apt  to  be  nauseated 
and  perhaps  vomits.  The  vaginal  discharge,  which  perhaps  at  first  was 
only  mucus,  now  contains  a  little  blood,  due  to  the  separation  of  the 
membranes  from  the  cervix  and  lower  uterine  segment.  •  With  the  down- 
ward pressure  of  the  fluid  wedge,  produced  by  the  unbroken  amniotic  sac, 
together  w^ith  the  retraction  of  the  cervix  and  the  lower  uterine  segment, 
the  cervical  canal  gradually  dilates  until  its  diameter  is  greater  than 
the  width  of  four  fingers  of  the  examining  hand.  Usually  at  this  time, 
during  one  of  the  uterine  contractions,  in  obstetrics  called  "pains,"  the 
amniotic  sac  bursts  with  the  escape  of  considerable  liquor  amnii.  The 
amount  of  this  first  escape  varies  greatly  with  the  amount  present  in  the 
uterus,  with  the  presentation  of  the  child  and  with  the  point  of  rupture. 
If  it  is  a  vertex  presentation  and  the  head  is  descending  normally  in  the 
pelvis  but  a  little  may  escape  at  first,  as  the  head,  acting  like  a  ball 
valve,  plugs  the  opening  for  a  time.  Then  with  each  pain  a  little  more 
escapes,  keeping  the  canal  moist.  On  the  other  hand,  if  the  presentation 
is  transverse,  or  the  head  is  not  engaged,  all  the  liquor  amnii  may  escape 
at  the  time  of  rupture.  If  the  point  of  rupture  of  the  amniotic  sac  is 
high  up,  the  amount  which  escapes  at  the  time  of  rupture  may  be  very 
slight.  At  times  the  rupture  of  the  membranes  is  the  first  evidence  of 
the  onset  of  labor  and  the  woman  may  be  aroused  from  sleep  by  a  gush 
of  water  which  soaks  her  night-dress.  As  in  this  case  there  has  probably 
been  but  slight  engagement  of  the  presenting  part,  usually  a  large  propor- 
tion of  the  liquor  amnii  drains  away  and  there  results  a  so-called  "dry 
labor,"  one  in  which  the  fluid  wedge  to  aid  in  dilating  the  cervix  is  absent 
and  hence  a  labor  which  is  apt  to  be  long  and  tedious. 

Sometimes  rupture  of  the  membranes  occurs  several  days  or  even 
weeks  before  the  onset  of  labor,  but,  as  a  rule,  labor  pains  begin  within 
twenty-four  hours,  and  according  to  my  experience  it  is  fortunately  so, 
as  several  cases  have  come  under  observation  where,  after  the  escape  of 
the  liquor  amnii,  the  long  pressure  upon  the  child  and  the  entrance  of 
air  to  the  amniotic  sac  has  apparently  caused  the  death  of  the  child  and 
infection  of  the  mother. 
14 


210 


NORMAL  LABOR 


For  these  reasons  it  is  my  custom  to  start  the  induction  of  labor  in 
a  patient  whose  pains  do  not  begin  in  twenty-four  hours  after  the  rupture 
of  the  membranes.  As  to  the  duration  of  the  first  stage  of  labor,  it  is  very 
difficult  to  predict. 

In  5000  normal  labors  at  the  Sloane  Hospital,  of  which  2500  were 
primigravidse  and  2500  multigravidse,  the  average  duration  of  the  first  and 
second  stages  was  as  follows: 

Primigravidse :  first  stage,  fourteen  hours,  six  minutes;  second  stage, 
one  hour,  twenty-five  minutes;  total  labor,  fifteen  hours,  thirty-one 
minutes. 


Fjg.  152. — Upper  and  luwer  uterine  segments  separated  l)y  the  ring  of  Bandl.     (Bumm, 

after  Braune.) 


Multigravidae :  first  stage,  ten  hours,  twenty-five  minutes;  second 
stage,  one  hour,  five  minutes;  total  labor,  eleven  hours,  thirty  min- 
utes. 

Fourteen  hours  in  the  primigravida  and  ten  and  one-half  hours  in  a 
multigravida  may  therefore  be  taken  as  the  average  duration  of  the 
first  stage. 

Changes  in  the  Uterus  during  the  First  Stage. — With  the  onset  of  labor 
the  uterus  is  seen  to  divide  itself  into  two  portions  or  segments:  The 
upper  uterine  segment  and  the  loiver  uterine  segment  separated  by  a  cir- 
cular band  which  represents  the  lower  edge  of  the  upper  uterine  segment 


DILATATION  OF  THE  CERVIX  211 

and  is  usually  called  the  ring  of  Bandl  (see  Fig.  152),  although  previously 
described  by  Braune  in  his  study  of  frozen  sections.' 

The  upper  uterine  segment  is  active  and  becomes  thickened  as  labor 
advances.  The  composition  of  the  lower  uterine  segment  has  been  the 
subject  of  much  discussion,  but  it  is  generally  regarded  as  formed  in 
part  by  the  lower  portion  of  the  uterus  just  above  the  internal  os  and 
by  the  cervix  itself.  This  lower  uterine  segment  becomes  thinned  as 
labor  advances;  is  largely  passive  during  the  process,  and  shows  a 
gradual  obliteration  of  the  cervical  canal  from  above  downward  by  a 
funnel-shaped  dilatation.  The  internal  os  gradually  disappears  and 
leaves  the  lower  uterine  segment  a  thin,  muscular  canal,  bounded  above 
by  the  contraction  ring,  or  ring  of  Bandl,  below  by  the  external  os  which 
in  primigravidse  may  be  thin,  sharp  and  rigid  for  a  time,  but  in  multi-  ^ 
gravidae  is  usually  much  more  patulous  and  readily  dilatable. 

The  contraction  ring,  called  also  retraction  ring  by  Lusk,  which  is 
marked  only  during  labor,  is  situated  at  a  height  in  the  uterus  corre- 
sponding to  the  reflection  of  the  peritoneum  from  the  uterus  on  to  the 
bladder,  and  is  opposite  a  large  coronary  vein.  Although  beginning  in 
the  first  stage,  the  contraction  ring  is  usually  not  well  marked  until 
the  second  stage  of  labor. 

In  the  normal  mechanism  of  dilatation  of  the  cervix,  aside  from  the 
contractile  power  of  the  upper  uterine  segment,  aided  perhaps  by  the 
voluntary  action  of  the  muscles  of  the  abdominal  wall,  we  have  four 
factors  at  work: 

1.  Softening  of  the  cervix. 

2.  The  action  of  the  fluid  wedge. 

3.  The  action  of  the  solid  wedge. 

4.  The  retraction  of  the  lower  uterine  segment. 

Softening  of  the  Cervix. — During  the  latter  part  of  pregnancy  on  account 
of  pressure  from  above  and  interference  with  \-enous  return,  the  cervix 
becomes  more  congested,  hj-peremic,  softened  and  more  dilatable.  With 
the  onset  of  labor  this  hyperemia  and  serous  infiltration  increases,  es- 
pecially during  uterine  contractions,  and  when  the  thorax  is  fixed  and 
the  abdominal  muscles  are  brought  mto  play.  The  softening  of  the 
cervix  greatly  aids  in  dilatation,  as  is  seen  in  placenta  previa  where  the 
increased  vascularity  and  softening  usually  renders  the  cervix  easily 
dilatable. 

Fluid  Wedge. — During  uterine  contractions  the  fluid  contents  of  the 
uterus  are  subjected  to  pressure  and,  although  this  pressure  is  transmitted 
equally  in  all  dhections,  its  eftect  is  most  marked  in  the  direction  of 
least  resistance.  As  the  cervix  is  perforated  by  its  canal  this  naturally 
is  the  direction  of  least  resistance  and  the  contractions  of  the  uterus 
force  a  sac  of  fluid  into  and  through  the  cervical  canal,  serving  as  the 
most  important  means  of  dilatation.  The  effect  of  the  absence  of  the 
cervical  canal  is  occasionally  seen  in  cases  where  the  canal  has  been 
obliterated  durmg  pregnancy  by  some  inflammatory  process,  and  during 

1  Die  Lage  des  Uterus  und  Fotus  am  Ende  der  Schwangerschaft,  Leipzig,  1872. 


212 


NORMAL  LABOR 


labor  uterine  contractions  continue  for  hours  without  dilatation  of  the 
cervix  until  an  artificial  opening  is  made,  when  dilatation  proceeds 
rapidly. 


Fig.   153. — In  the-  interval  between  uterine  contractions. 

The  Solid  Wedge. — If  rupture  of  the  membranes  has  taken  place  early 
in  labor,  instead  of  the  fluid  wedge  produced  by  the  conical  sac  of  amniotic 
fluid,  nature  has  in  its  place  the  solid  wedge  formed  by  the  presenting 


Fig.   154. — Same  patient  as  Fis-  15.3,  during  a  uterine  contraction. 

part   which    becomes  more   and    more    conical    through    pressure    and 
molding. 

As  is  well  known,  even  to  the  laity,  the  solid  wedge  with  its  accompany- 
ing dry  labor  is  much  more  tedious  for  the  patient  than  one  with  the 


STAGES  OF  LABOR  213 

membranes  intact,  and  is  more  apt  to  expose  the  child  to  a  dangerous 
amount  of  pressure. 

Retraction  of  the  Lower  Uterine  Segment. — Although  during  labor  the 
lower  uterine  segment  is  regarded  as  largely  passive,  apparently  through 
the  action  of  the  longitudinal  fibers  of  the  upper  segment,  it  is  gradually 
retracted  over  the  presenting  amniotic  sac  or  presenting  fetal  part,  and 
this  process,  taken  in  conjunction  with  the  action  of  the  fluid  or  solid 
wedge,  accomplishes  the  dilatation  of  the  cervix. 

During  the  first  stage  of  labor  if  the  patient  is  lying  on  her  back  (see 
Fig.  153)  the  abdominal  wall  during  the  interval  between  uterine  con- 
tractions is  flaccid  and  the  uterus  itself  is  not  tense.  During  a  uterine 
contraction,  however,  the  abdominal  and  uterine  muscles  become  tense 
and  the  uterus  stands  out  from  the  abdominal  cavity,  increasing  its 
anteroposterior  diameter  and  diminishing  its  transverse  diameter  (see 
Fig.  154). 

Second  Stage. — ^Yith  the  completion  of  the  dilatation  of  the  cervix 
the  characteristics  of  the  labor  change.  The  patient  instead  of  being 
up  and  walking  about  instinctively  takes  to  her  bed.  Her  pains  become 
more  regular,  harder  and  expulsive  in  character.  During  the  latter  part 
of  the  first  stage  she  may  have  voluntarily  during  each  pain,  held  her 
breath  and  brought  into  action  her  abdominal  muscles,  but  now  this 
action  becomes  involuntary.  She  has  the  desire  to  press  her  feet  against 
something;  she  fixes  the  muscles  of  her  thorax  and  her  diaphragm;  she 
wishes  to  pull  upon  something  w^th  her  arms;  she  uses  her  abdominal 
muscles  to  the  best  of  her  ability,  thus  greatly  supplementing  the  expul- 
sive power  of  the  uterus. 

The  pressure  of  the  presentiag  part  upon  the  rectum  gives  the  patient 
the  feeliug  that  her  bowels  are  to  move,  and  she  so  expresses  herself. 

During  the  pains  her  face  becomes  flusTied  and  her  pulse  more  rapid 
while  the  fetal  heart  becomes  a  little  slower.  At  the  height  of  each  pain 
she  lets  out  her  breath  with  a  grunt.  During  this  stage  she  seems  to 
realize  that  she  is  reaching  the  end  of  her  suffering,  that  there  is  work 
for  her  to  do,  and  although  during  the  latter  part  of  the  first  stage  she 
may  have  been  nervous,  irritable  and  discouraged,  she  now  summons 
her  strength  and  will-power  and  is  anxious  to  assist  nature  in  every  way 
that  she  can.  She  soon  learns  that  by  holding  her  breath  and  not  crying 
out  with  the  pain  she  can  make  better  progress,  and  acts  accordingly. 

This  picture  of  a  woman  with  flushed  face,  knees  flexed,  straining  with 
each  uterine  contraction,  anxious  to  pull  on  something  with  her  arms, 
and  giving  an  expulsive  cry  at  the  acme  of  each  pain  is  a  picture  of  the 
second  stage  of  labor  familiar  to  every  obstetrician. 

Changes  in  the  Uterus  during  the  Second  Stage.— At  the  completion  of 
the  dilatation  of  the  cervix  the  need  for  the  fluid  wedge  formed  b}'  the 
amniotic  sac  ceases  and,  as  a  rule,  the  membranes  forming  the  sac, 
i.  e.,  the  amnion,  chorion  and  decidua  capsularis  (reflexa),  usually  spoken 
of  as  the  "membranes,"  rupture  and  more  or  less  of  the  liquor  amnii 
escapes,  moistening  the  parts  below 

As  aheady  stated,  however,  the  membranes  may  rupture  at  the  onset 


214  NORMAL  LABOR 

of  labor  or  even  before  this  event  occurs,  and  on  the  other  hand  in  rare 
cases  the  rupture  may  not  take  place  until  after  the  birth  and  the 
fetus  he  born  surrounded  by  the  unruptured  membranes,  that  portion 
covering  the  fetal  head  being  spoken  of  as  a  "caul." 

The  point  of  rupture  is  usually  in  the  axis  of  the  vagina,  but  occasion- 
ally it  is  high  up  laterally,  allowing  only  a  little  liquor  amnii  to  escape 
gradually,  followed  later  by  a  gush  when  the  sac  lying  just  in  front  of 
the  head  and  containing  the  "forewater"  ruptures.  When  the  mem- 
branes fail  to  rupture  after  the  dilatation  of  the  cervix  is  complete,  labor 
is  usually  delayed  by  it. 

In  the  second  stage  the  fundus  during  uterine  contractions  not  only 
moves  forward  but  settles  a  little  in  the  abdomen,  only  to  rise  again 
as  the  contraction  passes  off.  Permanent  lowering  of  the  fundus  does 
not  usually  occur  until  the  presenting  part  begins  to  emerge  from  the 
vulva. 

Patients  may  often  wisely  be  told  of  this  fact  during  their  period  of 
discouragement  in  the  first  stage  when  their  abdominal  swelling  does 
not  descend  as  a  result  of  their  numerous  pains.  The  division  into  the 
upper  and  lower  uterine  segments  which  was  gradually  taking  place 
during  the  first  stage  now  becomes  more  marked  and  the  retraction  or 
contraction  ring  is  more  distinct.  If,  on  account  of  some  disproportion 
between  the  presenting  part  and  the  pelvic  canal,  there  is  obstruction 
to  the  advance  of  the  child,  the  lower  uterine  segment  becomes  more 
and  more  distended,  while  the  upper  segment  contracts  and  retracts, 
so  that  instead  of  the  contraction  ring  being  situated  about  midway 
between  the  symphysis  and  the  umbilicus,  it  may  lie  but  little  below  the 
latter.  A  vaginal  examination  during  the  second  stage  in  a  normal 
labor  shows  the  vulva  more  congested  and  dilatable,  perhaps  a  thin 
rim  of  cervix  in  the  fornices  crowning  the  presenting  vertex,  which  is 
becoming  more  and  more  molded  as  the  caput  forms.  During  each 
pain  this  presenting  part  will  be  felt  to  advance,  only  to  recede  again 
as  the  pain  passes  oft'.  No  student  of  nature  can  fail  to  be  impressed 
with  the  changes  which  are  now  to  take  place  in  the  pelvic  floor  as  the 
presenting  part  descends  to  the  outside  world.  No  matter  how  many 
times  one  has  watched  the  process,  each  but  adds  to  the  conviction  of 
the  wonderful  provision  and  adaptability  of  nature  in  the  construction 
of  a  pelvic  floor  and  canal  which  at  other  times  furnishes  the  support 
needed  for  the  pelvic  organs  and  a  canal  which  just  admits  the  male 
organ  or  the  fingers  for  examination  and  during  labor  dilates  without 
injury  to  a  size  sufficient  to  allow  the  passage  of  a  full-sized  child  at  term. 

Should  the  vulva  be  watched  from  the  early  part  of  the  second  stage 
of  a  normal  labor  the  parts  will  be  seen  becoming  more  congested  with 
each  pain,  perhaps  with  the  extrusion  of  a  little  blood-stained  mucus; 
then  with  each  pain  there  is  a  little  gaping  of  the  vulva  as  the  head 
approaches  the  outlet.  Soon  at  the  height  of  a  pain  will  be  detected  a 
small  portion  of  the  caput  slightly  separating  the  labia  (see  Fig.  155). 
The  whole  pelvic  floor  begins  to  bulge  a  little  with  each  pain,  the  anus 
pouts  and  begins  to  dilate  and  more  and  more  of  the  caput  appears. 


STAGES  OF  LABOR 


215 


Thus,  with  advances  during  each  contraction  of  the  uterine  and  abdomi- 
nal muscles  and  recessions  during  each  relaxation,  more  and  more  of 
the  head  appears,  gradually  extending  as  the  occiput  emerges  under 
the  pubic  arch  and  bends  upward  toward  the  mons  veneris,  while  the 
forehead,  nose,  mouth  and  chin  sweep  over  the  edge  of  the  perineum 
and  the  edge  of  the  vulva  slips  backward  to  the  neck  of  the  child. 

Thus  it  is  that  the  most  acute  suffering  of  the  labor  is  ended  and  the 
head  is  born,  soon  to  be  followed  by  the  body  of  the  child,  and  the  second 
stage  is  ended. 

Third  Stage. — After  the  birth  of  the  child  the  woman  experiences  a 
feeling  of  relief.  The  freedom  from  the  suffering  which  probably  has 
lasted  for  hours,  coupled  with  the  joy  that  her  long-anticipated  child  is 


Fig.   155. — Caput  appearing  at  \'ulvar  outlet. 


born,  brings  to  the  true  mother  such  mental  and  physical  peace  as  can 
only  be  appreciated  by  those  who  have  passed  through  it.  A  hand 
placed  on  the  abdomen  detects  the  uterus  now  greatly  reduced  in  size, 
lying  a  few  centimeters  below  the  luubilicus.  It  is  fairly  firm,  although 
not  as  hard  as  during  the  previous  uterine  contractions.  As  the  hand  is 
kept  upon  it,  the  uterus  is  felt  after  a  few  moments  to  alternately  relax 
and  contract.  At  first  these  contractions  are  not  severe  enough  to  cause 
pain  to  the  patient,  but  soon  they  become  more  severe  and  painful,  con- 
tinuing until  the  placenta  is  expelled  from  the  bod}"  of  the  uterus. 

If  the  abdomen  is  watched  its  contour  is  seen  to  change  as  time 
passes. 

Changes  in  the  Uterus  during  the  Third  Stage. — The  uterus  instead  of 
remaining  globular  becomes  more  elongated  and  rises  in  the  abdomen. 


216  NORMAL  LABOR 

At  the  same  tiint-  a  prominence  appears  just  above  the  symphysis. 
CorresponcHng  with  tiiis  change  in  contour  the  placenta  has  been  ex- 
pelled from  the  body  of  the  uterus  into  the  cervix  and  vagina.  In  a 
normal  case  this  usually  occurs  in  from  fi\e  to  thirty  minutes.  With 
this  descent  of  the  placenta  there  occurs  a  corresponding  increase  in 
the  length  of  cord  which  lies  outside  the  vagina.  With  the  birth  of  the 
child  there  takes  place  the  discharge  of  the  remainder  of  the  liquor 
amnii  and  following  this  there  is  usually  a  moderate  discharge  of  blood. 

Occasionally  the  placenta  is  expelled  almost  immediately  after  the 
birth  of  the  child,  but  this  is  very  exceptional.  As  a  rule,  after  the 
placenta  has  been  expelled  from  the  active  upper  uterine  segment  into 
the  passive  lower  uterine  segment  and  vagina  it  remains  there  for  an 
indefinite  period. 

According  to  Ahlfeld,  a  spontaneous  expulsion  occurred  in  only  13.6 
per  cent,  of  his  cases,  although  he  waited  from  one-half  to  two  hours. 
The  chief  factor  in  causing  the  normal  expulsion  of  the  placenta  from  the 
lower  uterine  segment  and  vagina  is  the  voluntary  contraction  of  the 
abdominal  muscles,  although,  of  course,  gravity  and  the  contraction  of 
the  vagina  are  auxiliary  forces. 

Separation  of  the  Placenta. — There  are  two  chief  views  regarding  the 
method  of  separation  of  the  placenta  from  the  uterine  wall,  bearing 
respectively  the  names  of  Shultze  and  Mathews  Duncan.  According  to 
the  view  of  Schultze,  the  middle  of  the  placenta  is  separated  first  and  is 
pushed  forward  by  a  blood  eflfusion  beneath  it  and  the  placenta  is  expelled 
like  an  inverted  umbrella  co^•ered  by  the  fetal  membranes  which  also 
trail  behind  it. 

In  this  method  of  expulsion  there  is  no  external  bleeding  until  after 
the  birth  of  the  placenta. 

According  to  the  view  of  Mathews  Duncan,  the  placenta  is  separated 
at  the  edge,  especially  the  lower  edge  first.  It  is  then  folded  upon  itself 
like  a  roll  within  the  cavity  of  the  uterus  and  is  expelled,  edge  first,  with 
or  without  the  inversion  of  the  membranes.  In  this  method  of  expul- 
sion there  is  no  marked  retroplacental  hemorrhage,  but  a  moderate 
continuous  bleeding  from  the  birth  of  the  child  to  the  birth  of  the  pla- 
centa, this  bleeding  being  more  marked  if  the  membranes  are  not 
inverted. 

The  Duncan  view  is  the  one  most  generally  held  in  this  country  and 
is  probably  the  usual  method  of  expulsion  when  the  placental  attach- 
ment is  lateral  or  on  the  anterior  or  posterior  uterine  wall.  If  the  pla- 
centa is  attached  to  the  fundus  of  the  uterus  the  method  of  Schultze  is 
probably  often  followed. 

It  seems  to  the  author  most  rational  to  consider  that  in  ordinary  cases 
as  the  uterus  contracts  the  placenta  is  compressed  and  at  first  allows  of 
this  compression  without  separation,  its  contained  fetal  blood  being 
expressed  along  the  untied  umbilical  cord  to  the  fetus;  that  after  a 
little  time  the  contraction  and  shrinkage  of  the  placental  site  detaches 
it  from  the  placenta  which  then  becomes  a  foreign  body  in  the  uterus 
and  as  the  uterus  is  always  stimulated  to  expell  any  foreign  body  from 


EXPULSION  OF  THE  PLACENTA  217 

within  its  cavit}'  so  the  upper  uterine  segment  is  stimulated  to  expel 
the  placenta. 

On  examining  the  maternal  surface  of  the  freshly  expelled  placenta 
it  is  found  that  the  separation  has  taken  place  in  the  decidua  basalis 
and  that  a  thin  layer  of  this  decidua  is  still  attached  to  it. 

In  the  above  description  the  author  has  endeavored  to  describe  the 
third  stage  of  labor  as  left  to  nature,  but  as  will  be  seen  in  the  chapter 
discussing  the  Management  of  Normal  Labor  (see  page  341),  it  is  not 
considered  good  practice  to  leave  the  expulsion  of  the  placenta  to  nature's 
unaided  efforts.  As  the  placenta  may  remain  in  the  cervix  and  vagina 
for  an  indefinite  period  and  the  discomforts  of  the  patient  are  prolonged 
by  the  delay,  with  the  probability  of  greater  loss  of  blood  and  perhaps 
danger  of  infection,  it  seems  to  the  writer  that  within  a  reasonable 
time,  as  will  be  discussed  later,  the  expulsion  of  the  placenta  should  be 
aided. 

I  As  to  the  edge  and  surface  of  the  placenta  which  is  first  expelled, 
and  the  average  maternal  blood  loss  with  each,  the  study  of  the  late 
Dr.  Ervin  A.  Tucker^  at  the  Sloane  Hospital  gave  the  following  results: 
Of  the  2710  placental  births  which  were  studied,  2561  were  expressed 
by  the  Crede  method,  while  149  came  away  spontaneously.  The  fre- 
quency of  the  edge  and  surface  of  the  placenta  born  first  in  these  two 
different  methods  of  expulsion  may  be  seen  from  the  following  table: 

Crede  expression.  Spontaneous  expression. 

979  =38.2  per  cent.  49  =32.9  per  cent.,  were  born  edge  first,  fetal  surface  out. 

703   =27.4  per  cent.  26  =  17.4  per  cent.,  were  born  fetal  surface  first  and  out. 

555   =21.7  per  cent.  47   =31.6  per  cent.,  were  born  edge  first,  maternal  surface  out. 

194  =     7.6  per  cent.  21   =  14. 1  per  cent.,  were  born  maternal  surface  first  and  out. 
130  =    5.1  per  cent.  6  =    4.0  per  cent.,  were  born  edge  first. 

The  summary  of  the  2561  placental  births  under  the  Crede  method 
of  expression  gives: 

1682  =  65.6  per  cent.,  born  fetal  surface  out. 
749  =  29.3  per  cent.,  born  maternal  surface  out. 
130  =     5.1  per  cent.,  born  edge  first. 

It  will  thus  be  seen  that,  as  observed  clinically,  the  frequency  of  the 
birth  of  the  fetal  surface  out  under  the  Crede  method  of  expression  is 
more  than  twice  that  of  the  maternal  surface  out. 

Tucker  also  found  that  the  amount  of  maternal  blood  loss  in  these 
2710  placental  births  varied  with  the  edge  and  surface  first  born  as  follows : 

Average  loss  when  placenta  born  edge  first,  maternal  surface  out,  10.8 
ounces  (most). 

Average  loss  when  placenta  born  maternal  surface  first  and  out,  10.4 

ounces. 

Average  loss  when  placenta  born  edge  first,  fetal  surface  out,  10  ounces. 
Average  loss  when  placenta  born  edge  first,  9.2  ounces. 

1  Birth  of  the  Secundines,  Amer.  Gyn.  and  Obst.  Journal,  May,  190S. 


218  NORMAL  LABOR 

Average  loss  when  placenta  born  fetal  surface  first  and  out,  8.S  ounces 
(least). 

Following  the  birth  of  the  child  and  placenta  the  patient  often  expe- 
riences various  chilly  sensations  which  may  amount  to  a  distinct  rigor. 

It  is  purely  physiological,  probably  of  vasomotor  origin  and  need 
occasion  no  alarm,  as  it  is  not  accompanied  by  a  rise  of  temperature 
or  pulse  and  soon  passes  off  with  no  other  treatment  than  a  warm  blanket. 

Its  importance  rests  in  distinguishing  it  from  the  chill  occurring  later 
in  the  puerperium  which  usually  indicates  infection. 


CHAPTER  VIII. 

THE  MECHANISM  OF  LABOR. 

By  the  mechanism  of  labor  is  meant  the  manner  in  which  the  con- 
tents of  the  pregnant  uterus,  the  fetus  and  the  placenta,  are  propelled 
through  the  birth  canal  and  enter  the  outside  world.  It  is  in  the  birth 
of  the  fully  developed  fetus  that  nature  exhibits  this  mechanism  in  its 
most  perfect  shape;  the  birth  of  the  premature  fetus  and  of  the  placenta 
being  accomplished  in  a  comparatively  simple  manner. 

In  the  enlarged  uterus  is  the  fetus,  fully  developed,  and  only  awaiting 
its  birth  into  the  outer  world  to  become  a  breathing,  growing  human 
being.  That  this  body  so  large,  yet  so  delicate  in  structure  can  in  the 
course  of  a  few  hours  be  pushed  through  the  narrow  birth  canal  of  the 
mother  without  serious  injury  to  either  mother  or  child  seems  little  short 
of  marvellous  and  may  well  excite  admiration,  yet  it  is  an  every-day 
occurrence. 

For  a  thorough  understanding  of  the  mechanism  of  labor  the  three 
factors  involved  should  be  studied : 

The  parturient  canal  or  passage. 

The  fetus  or  passenger. 

The  propelling  force. 

THE  PARTURIENT  CANAL  OR  PASSAGE. 

The  parturient  canal  or  passage  is  composed  of  both  hard  and  soft 
structures.  The  former  consisting  of  the  bony  pelvis;  the  latter  of  the 
muscles  and  fascise  lining  the  pelvis  and  forming  the  pelvic  floor  and  of 
the  muscular  canals  of  the  uterus,  vagina  and  vulva. 

The  hard  and  soft  structures  of  the  parturient  canal  will  be  studied 
separately,  the  bony  framework  of  the  canal  first  being  considered. 

The  Female  Pelvis. — Considered  obstetrically  the  pelvis  presents 
numerous  points  of  interest  (see  Fig.  156). 

It  is  composed  of  four  bones:  the  two  ossa  innominata;  the  sacrum 
and  the  cocc^oc,  each  composed  in  earl}^  life  of  separate  segments  united 
by  intervening  cartilage.  The  segments  of  the  innominate  bone,  the 
ilium,  the  ischium  and  the  pubes  are  the  earliest  to  unite,  presenting  firm 
bony  union  from  the  twentieth  to  the  twenty-fifth  year.  The  sacral 
and  coccygeal  segments  fuse  still  later,  those  of  the  coccyx  remaining 
movable  until  middle  life.  The  coccyx  does  not  normally  become  firmly 
joined  to  the  apex  of  the  sacrum  until  late  in  life. 

Consideration  of  the  above  method  of  pelvic  development  demon- 
strates the  fact  that  during  the  usual  child-hearing  age  the  segments  com- 
yosing  the  posterior  wall  of  the  yelins  are  not  firmly  united. 

(219) 


220 


THE  MECHANISM  OF  LABOR 


Furthennore,  the  mobility  of  the  saerococcygeal  joint  allows  consider- 
able motion  in  the  anteroposterior  direction,  often  amounting  to  2  cm. 
or  more,  thus  meeting  the  demand  during  labor  for  greater  room  at  the 


Fig.  150. — The  female  pelvis. 


Fig.   157. — Increase  of  the  conjugate  diameter  of  the  outlet  by  recession  of  the  coccyx. 

outlet.  This  is  illustrated  in  Fig.  157,  which  represents  the  increase  of 
the  conjugate  diameter  of  the  outlet  from  9.5  cm.  to  11.5  cm.,  bj'  a 
recession  of  the  coccyx  imder  the  pressure  of  the  presenting  part. 


THE  PARTURIENT  CANAL  OR  PASSAGE 


221 


The  space  included  within  this  bony  framework  is  divided  into  two 
parts  by  a  plane  passing  through  the  upper  border  of  the  symphysis 
pubis  in  front,  the  linea  iliopectinea  on  either  side,  and  the  middle  of  the 
sacral  promontory  behind,  called  the  plane  of  the  iyilet  or  the  jpJane  of 
the  superior  strait.  The  portion  above  this  plane,  or  imaginary  level, 
is  called  the  false  pelvis,  while  that  below  is  the  true  pelvis  which  is 
chiefly  concerned  in  the  mechanism  of  labor. 

The  False  Pelvis. — The  false  pelvis  has  relatively  little  importance  in 
the  process  of  labor,  it  serves  as  a  sort  of  funnel  to  guide  the  presenting 
part  into  the  true  pelvis  and  as  a  support  to  the  contents  of  the  lower 
abdomen,  the  intestines  in  the  non-pregnant  state  and  the  enlarging 
uterus  as  well  as  the  intestines  in  the  pregnant  state. 


Fig.   158.^The  peh^ic  inlet,  seen  from  above. 

The  false  pelvis  really  forms  a  part  of  the  abdominal  cavity,  being 
bounded  behind  by  the  lower  portion  of  the  lumbar  spme,  laterally 
by  the  iliac  fossae,  and  anteriorly  by  the  lower  part  of  the  abdominal 
wall. 

The  Pelvic  Inlet. — ^The  bony  ring  or  dividing  line  between  the  false 
pelvis  above  and  the  true  pelvis  below  is  variously  spoken  of  as  the 
brim,  the  superior  strait,  or  the  pelvic  inlet.  It  is  irregularly  oval  in 
shape  with  longest  diameter  running  transversely  (see  Fig.  158).  A 
depression  is  made  in  the  posterior  side  of  the  oval  by  the  projection  of 
the  promontory  of  the  sacrimi.  In  describing  the  size  and  shape  of  the 
pelvic  inlet  four  diameters  are  considered:  The  anteroposterior  diameter, 
or  the  true  conjugate,  extending  from  the  middle  of  the  promontory  of  the 
sacriun  to  the  upper  border  of  the  s^^nphysis  pubis.  This  normally  gives 
an  average  measurement  of  llcm. 


222 


THE  MECHANISM  OF  LABOR 


The  oblique  diameters,  taken  from  the  sacro-iliac  joint  on  one  side,  to 
the  iliopectineal  eminence  of  the  opposite  side.  These  diameters  are 
called  the  right  or  left  obliciue,  according  to  whether  it  is  the  right  or 
left  sacro-iliac  joint  which  enters  into  the  measnrement. 

Thus  the  right  oblique  diameter  of  the  pelvic  inlet  is  the  distance 
from  the  right  sacro-iliac  joint  to  the  left  iliopectineal  eminence  and 
vice  versa.  These  oblique  diameters  normally  give  an  average  measure- 
ment of  12  cm.,  the  right  being  usually  a  trifle  longer  than  the  left. 

The  tran.sverse  diameter  is  the  greatest  distance  across  the  pelvic  inlet 
taken  at  right  angles  to  the  true  conjugate.  It  usuall>'  lies  posteriorly 
to  the  centre  of  the  pelvis,  the  extremities  of  the  diameter  resting  about 
midway  between  the  sacro-iliac  joint  and  the  iliopectineal  eminence  on 
each  side.  The  average  measurement  of  this  diameter  is  usually  con- 
sidered 13  cm.    It  is  a  difficult  diameter  to  measure  and  is  seldom  accu- 


Fig.   159. — The  pelvic  cavity 


rately  taken  in  practice.  Although  as  stated  elsewhere,  it  is  the  longest 
diameter  of  the  pehic  inlet,  the  projection  forward  of  the  sacral  promon- 
tory prevents  its  being  the  diameter  most  available  for  entrance  of  the 
fetal  head  into  the  true  pelvis. 

The  True  Pelvis. — The  true  pelvis  is  that  portion  lying  beneath  the 
plane  of  the  pelvic  inlet  and  is  the  part  chiefly  concerned  in  the  mechan- 
ism of  labor.  It  is  bounded  below  by  the  plane  passing  through  the  tip 
of  the  cocc\x,  the  tuberosities  of  the  ischia  and  the  lower  border  of  the 
symphysis  pubis,  called  the  plane  of  the  outlet  or  the  plane  of  the  inferior 
strait.  This  is  hardly  a  mathematical  plane,  but  rather  two  triangular 
planes  whose  apices  are  at  the  coccyx  and  the  under  surface  of  the  sym- 
physis respectively,  and  whose  bases  meet  on  a  line  joining  the  two  ischial 
tuberosities.  The  cavity  of  the  true  pelvis  (see  Fig.  159)  is  bounded  in 
front  by  the  pubic  bones  and  the  rami  of  the  ischia,  laterally  by  the 


THE  PARTURIENT  CANAL  OR  PASSAGE 


223 


ischial  bones,  with  the  obturator  foramina  and  membranes  in  front, 
and  the  saerosciatic  notches  with  their  hgaments  and  muscles  behind. 
Posteriorly  the  pelvic  cavity  is  bounded  by  the  sacrmn  and  coccyx. 
It  is  thus  seen  that  the  only  portion  of  the  lateral  wall  formed  entirely 
by  bone  is  the  middle  portion  formed  by  the  body  of  the  ischium. 

The  middle  portion  of  the  lateral  pelvic  wall  is  of  distinct  importance 
in  the  mechanism  of  labor  and  deserves  further  consideration. 

As  stated  above,  this  portion  is  formed  solely  of  bone  and  is  entirel}- 
unyielding  while  the  portion  in  front,  filled  in  with  the  obturator  mem- 


FiG.   160. — Ridge  dividing  anterior  and  posterior  inclined  planes. 


brane  and  muscles,  allows  more  or  less  yielding,  as  does  the  portion  behind, 
filled  in  by  the  saerosciatic  ligaments  and  muscles.  Furthermore,  pro- 
jecting from  the  posterior  border  of  this  bony  middle  portion  is  a  sharp 
projection,  the  spine  of  the  ischium,  which  with  its  fellow  of  the  opposite 
side  causes  the  least  diameter  of  the  pelvic  cavity. 

Between  the  spine  of  the  ischium  (A,  Fig.  160)  and  the  iliopectineal 
eminence  (B)  is  a  ridge  more  or  less  marked  in  different  pelves,  which 
divides  the  pelvic  cavity  on  each  side  into  two  portions,  the  anterior 
and  posterior,  which  are  concave  from  above  downward  and  from  before 
backward.     These  may  well  be  called  the  anterior  and  posterior  pelvic 


224 


THE  MECHANISM  OF  LABOR 


grooves.  The  portion  of  the  ischial  body  in  front  of  tlie  ridge  joining 
the  spine  and  iUopectineal  eminence  is  in  obstetrics  often  called  the 
anterior  inclined  plane,  while  that  portion  behind  this  ridge  is  called 
the  posterior  inclined  plane.  Formerly  these  inclined  planes  were  thought 
to  be  important  factors  in  the  rotation  of  the  presenting  part.  It  is  now 
known  that  they  are  merely  guiding  slopes  to  the  pelvic  floor,  which  is 
the  chief  factor  in  the  rotation. 

The  dividing  ridge  may  be  compared  to  the  ridge  pole  of  a  two-slope 
roof  (see  Fig.  195),  and  in  the  same  way  that  a  ball  falling  on  one  side 
of  the  ridge  pole  will  roll  down  one  side'  of  the  roof,  and  falling  on  the 
other  side  of  the  ridge  pole  will  roll  down  the  opposite  side  of  the  roof, 
so  in  the  pelvis.     If  the  occiput,  for  instance,  impinges  on  one  of  the 


Fig.  161. — The  pelvic  outlet,  seen  from  below. 


anterior  inclined  planes,  it  tends  to  descend  to  the  floor  of  the  pelvis  in 
one  of  the  anterior  pelvic  grooves,  giving  occipito-anterior  positions. 
While  if  it  impinges  on  one  of  the  posterior  inclined  planes,  it  tends  to 
descend  in  one  of  the  posterior  grooves,  giving  occipitoposterior  positions. 

This  will  be  referred  to  again  when  discussing  rotation  of  the  head  in 
vertex  presentations  (see  page  261). 

The  pelvic  cavity  is  shallow  in  front,  measuring  only  about  4  cm.  in 
depth,  and  deep  behind  where  it  measures  along  the  curve  of  the  sacrum 
and  coccyx  about  12.5  cm.  The  lateral  depth  is  approximately  9  cm.  The 
shape  of  the  pelvic  cavity  is  therefore  that  of  a  curved,  obliquely  trun- 
cated cylinder,  the  curve  presenting  the  concavity  forward,  as  though 
bent  about  the  symphysis,  although  the  greater  part  of  this  curve  is  in 
the  lower  part  of  the  cavity  rather  than  the  upper.    For  practical  pur- 


THE  PARTURIENT  CANAL  OR  PASSAGE  225 

poses  the  diameter  of  the  normal  pelvic  cavity  may  be  considered  the 
same  in  all  directions  and  averages  12  cm. 

The  Pelvic  Outlet. — The  pelvic  outlet,  or  the  inferior  strait,  is  of  irregular 
shape  (see  Fig.  161),  bounded  in  front  by  the  pubic  arch,  laterally  by 
the  ischial  tuberosities  and  the  greater  sacrosciatic  ligaments,  and  pos- 
teriorly by  the  tip  of  the  coccyx.  When  the  coccyx  is  in  its  normal  posi- 
tion this  diameter,  as  already  stated,  averages  9.5  cm.,  but  may  be 
increased  to  11.5  cm.  when  the  coccyx  is  pushed  backward  during  the 
birth  of  the  child  (see  Fig.  157). 

The  transverse  diameter  of  the  outlet  is  the  distance  between  the 
inner  margins  of  the  ischial  tuberosities  and  averages   11   cm.     The 
measurements  of  the  other  external  diameters  of  the  pelvis  are  considered ' 
under  the  subject  of  Pelvimetry. 

Pelvic  Planes. — The  planes  of  the  pelvis  are  imaginary  levels  taken 
at  any  height  in  the  canal.  Of  course  these  could  be  innumerable  but 
in  practical  obstetrics  only  four  are  considered.  Two  of  them,  the  j^^ane 
of  the  inlet  and  the  playie  of  the  outlet,  have  already  been  considered  in 
studying  the  brim  and  outlet  of  the  true  pelvis.  In  addition  to  these, 
two  other  planes  are  recognized  as  of  importance,  the  jjlane  of  the  greatest 
pehic  dimensions,  first  described  by  Levret,  and  the  plane  of  the  least 
pelvic  dimensions.  The  former  passes  from  the  middle  of  the  posterior 
surface  of  the  symphysis  pubis  through  the  middle  of  the  back  of  the 
acetabula  to  the  junction  of  the  second  and  third  sacral  vertebrae.  This 
plane  gives  the  largest  diameters  of  the  cavity;  being  larger  than  those 
of  the  inlet.  The  plane  of  the  least  pelvic  dimensions  passes  through  the 
lower  margin  of  the  symphysis  pubis,  the  spines  of  the  ischia  and  the  tip  of 
the  sacrum.  This  plane,  as  its  name  implies,  gives  the  smallest  diameters 
of  the  cavit.y,  being  smaller  than  those  of  the  outlet. 

Pelvic  Axes. — ^The  axes  of  the  pelvis  are  imaginary  lines  drawn  at  right 
angles  to  the  centres  of  the  planes  of  the  pelvis;  thus  the  axis  of  the 
pelvic  inlet  or  superior  strait  would  be  a  line  which  if  projected  upward 
would  pass  approximately  through  the  lunbilicus  and  if  continued 
downward  would  strike  the  coccyx  near  its  tip  (see  Fig.  162).  The  axis 
of  the  pelvic  outlet  if  continued  upward  would  strike  the  promontory 
of  the  sacrum.  The  axes  of  the  planes  at  different  heights  in  the  canal 
would  form  tangents  to  a  curve  which  represents  approximately  the 
course  of  the  child  through  the  pelvis,  although  as  shown  by  Naegele, 
Pinard  and  others,  the  child  in  its  passage  through  the  bony  pelvis  does 
not  follow  this  curve,  called  the  curve  of  Cams,  accurately,  but  the  head 
normally  descends  almost  perpendicularly  to  about  the  level  of  the 
ischial  spines  before  it  begins  to  curve  forward. 

Inclination  of  the  Pelvis. — The  position  of  the  pelvis  in  its  relation  to 
the  spinal  column  varies  with  each  change  of  posture.  In  the  erect 
posture  the  base  of  the  sacrum  lies  about  9  cm.  above  the  upper  border 
of  the  symphysis  puhis  and  the  tip  of  the  coccyx  about  2  cm.  above  the 
summit  of  the  subpubic  arch,  hence  the  plane  of  the  inlet  and  the  plane 
of  the  outlet  each  make  an  angle  with  the  horizon.  The  former  an  angle 
of  about  60  degrees  and  the  latter  an  angle  of  about  10  degrees  (see  Fig. 
15 


226 


THE  MECHANISM  OF  LABOR 


103).    The  angle  which  the  plane  of  the  inlet  makes  with  the  horizon 
is  called  the  inclinnfion  of  the  pelris.    The  mobility  of  the  pelvis  at  the 


Fig.   162. — Planes  and  axes  of  the  pelvic  inlet  and  outlet. 


Pig.   lt)3. — Inclination  of  the  pelvis. 


sacro-iliac  joints  allows  of  slight  rotation  of  the  innominate  bones  iipoji 
the  sacrum,  thus  changing  the  pelvic  inclination  as  the  posture  changes. 
If  the  woman  Hes  in  the  Hthotomy  position  (see  P'ig.  164)  the  plane 


THE  PARTURIENT  CANAL  OR  PASSAGE 


22V 


of  the  inlet  makes  with  the  horizon  an  angle  of  40  degress.  If  she  lies  in 
the  dorsal  posture  with  thighs  extended  the  pelvic  inclination  is  30 
degrees.    If  she  lies  with  hips  at  the  edge  of  the  table  and  thighs  hanging 


Fig.   164. — Pelvic  inclination  in  lithotomy  and  in  dorsal  position. 

downward,    the   so-called   Walcher   position,    the   pelvic   inclination    is 
only  about  12  degrees  (see  Fig.  165). 

Pelvic   Articulations. — Uniting  the  four  bones   M^hich   constitute   the 
pelvis  are  four  articulations:    the  two  sacro-iliac  the  sacrococcygeal,  and 


Fig.   165. — Pelvic  inclination  in  dorsal  and  in  Walcher  position. 

the  symphysis  pubis.  The  sacro-iliac  articulation  on  either  side  is  an 
amphiarthrodial  joint.  The  articular  surface  of  both  the  sacrum  and 
the  ilium  is  covered  with  a  thin  plate  of  cartilage  which  is  thicker  on  the 


228  THE  MECHANISM  OF  LABOR 

sacrum  than  on  the  ilium.  Separating  these  cartilaginous  plates  there 
has  been  demonstrated,  especialh'  during  pregnancy,  the  presence  of  a 
synovial  membrane  which  allows  of  a  certain  amount  of  motion;  this 
motion  being  a  rotation  of  the  innominate  bones  on  the  sacrum  so  that 
the  symphysis  is  elevated  or  depressed,  thus  allowing  a  change  in  the 
conjugate  diameter  during  labor.  The  ligaments  connecting  the  sacrum 
and  innominate  bones  are  the  anterior  and  posterior  sacro-iliac,  of  which 
the  posterior  are  much  the  stronger.  Instead  of  being  a  true  keystone 
of  the  pelvic  arch  the  sacrum  is  really  an  inverted  keystone  (see  Fig.  166), 
being  wider  in  front  than  behind,  and  would  tend  to  slip  downward  and 
forward  under  the  pressure  of  the  trunk  were  it  not  held  by  these  strong 
posterior  sacro-iliac  ligaments. 

The  sacrococcygeal  articulation  is  an  amphiarthrodial  joint  analogous 
to  those  between  the  bodies  of  the  vertebrae.  The  two  bones  are  con- 
nected by  the  anterior  and  posterior  sacrococcygeal  ligaments  and  an 


Fig.   16G. — The  sacrum  as  an  inverted  keystone. 

interposed  fibrocartilage.  This  fibrocartilage  is  somewhat  thicker  in 
front  and  behind  than  at  the  sides.  During  pregnancy  a  synovial 
membrane  is  usually  to  be  found  in  this  joint  which  allows  considerable 
mobility. 

Differences  between  the  Male  and  Female  Pelvis.— The  pelvis  of  the 
female  when  compared  with  that  of  the  male  presents  marked  differences 
which  adapt  it  to  the  important  function  of  maternitv,  as  seen  in  Figs. 
167  and  168. 

The  female  pelvis  is  lighter,  broader  and  more  shallow  than  the  male. 
The  points  of  muscular  attachment  are  less  strongly  marked  and  the 
pelvis  as  a  whole  is  less  massive  in  structure.  The  iliac  fossae  are  broader 
and  the  iliac  spines  more  widely  separated.  The  acetabula  are  farther 
apart,  hence  the  hips  of  the  woman  are  more  prominent. 

The  pubic  arch  is  wider,  measuring  90  to  100  degrees  in  the  female, 
as  compared  to  70  to  75  degrees  in  the  male. 


THE  PARTURIENT  CANAL  OR  PASSAGE 


229 


The  inlet  of  the  female  peh'is  is  larger  than  in  the  male,  as  the  promon- 
tory is  less  prominent  and  the  sacrmn  is  broader.    The  cavity  is  more 


Fig.   167. — Female  pelvis. 


shallow;  the  ischial  spines  project  less  into  the  canal;  the  curve  of  the 
sacrmn  is  usually  less,  hence  the  cavit}'  as  a  whole  is  more  roomy. 


Fig.   168.— Male  peh-is. 

The  outlet  of  the  female  pelvis  is  the  larger,  as  the  ischial  tuberosities 
are  farther  apart.  The  edges  of  the  wider  pubic  arch  are  more  everted 
and  the  coccvx  is  more  movable. 


230 


THE  MECHANISM  OF  LABOR 


Pelvic  Lining. — ^'ie^vell  ohstetrically  the  bony  pelvis,  both  the  false 
and  the  trne,  is  cushioned  with  muscles  and  fascia  in  such  a  way  that 
while  protecting;  the  uterus  and  its  contents  from  the  hard,  bony  struct- 
ure they  diminish  but  slightly  the  size  of  the  parturient  canal.  The 
funnel  of  the  false  pelvis  is  lined  by  the  iliacus  and  psoas  muscles  (see 
Fig.  1G9)  which  serve  as  a  cushion  for  the  uterus  and  its  contents  while 
above  the  brim. 

The  true  pehis  is  lined  by  two  muscles  on  each  side  the  obturator 
internus  and  the  pyriformis,  which  have  already  been  described  (see 
page  30). 

; 


Fig.   169. — False  pelvis  lined  by  the  iliacus  and  psoas  muscles. 

Stretching  across  the  outlet  of  the  pelvis  and  serving  both  as  a  cushion 
and  as  a  support  for  the  pelvic  organs  is  the  pelvic  floor  described  on 
page  31,  a  diaphragm  composed  chiefly  of  two  pairs  of  mu.scles,  the 
levatores  ani  and  the  coccygei,  with  the  fascial  and  connective  tissue 
covering  them.  This  diaphragm  is  perforated  by  the  urethra,  the  vagina 
and  the  rectum.  It  is  covered  above  by  the  peritoneum  and  below  by  the 
skin.  Between  the  skin  and  the  main  muscular  structure  of  the  dia- 
phragm (the  levatores  and  coccygei)  are  several  superficial  muscles  sur- 
rounding the  entrance  to  the  vagina  and  the  rectum  (see  page  35). 


THE  PARTURIENT  CANAL. 

The  parturient  canal  may  be  looked  upon  as  composed  of  two  portions, 
an  outer  canal,  consisting  of  the  abdominal  wall  and  the  bony  pelvis  with 


THE  PARTURIENT  CANAL  231 

the  muscles  and  fascise  forming  its  lining  and  floor,  and  an  inner  canal 
composed  of  the  uterus  and  vagina. 

The  muscular  canal  formed  hy  the  uterine  body  serves  also  as  a  propel- 
ling force  and  will  be  considered  later  under  that  heading  (see  page  241). 

It  will  here  be  studied  as  forming  a  part  of  the  parturient  canal. 

The  Uterine  Canal. — At  the  end  of  pregnancy  the  uterus  has  grown 
from  a  small  muscular  structure,  about  8  cm.  in  length  and  weighing  only 
an  ounce,  to  a  large  muscular  sac  about  36  cm.  long,  25  cm.  wide  and  24 
cm.  deep,  and  weighing  about  two  pounds.  It  has  been  estimated  by 
Krause  that  its  capacity  is  increased  519  times  during  pregnancy.  This 
enlargement  has  been  brought  about  both  by  an  hypertrophy  in  the 
individual  muscular  fibers  and  by  an  increase  in  their  number.  The  walls 
of  the  uterus  are  very  thin,  only  about  5  to  10  mm.  in  thickness,  and  very 
soft  and  yielding,  as  can  be  seen  by  watching  the  fetal  movements  in 
a  woman  with  thin  abdominal  walls. 

The  uterus  has  risen  from  the  pelvis  and  has  become  an  abdominal 
organ,  freely  movable,  held  chiefly  by  the  broad  ligaments,  and  changing 
in  position  with  the  posture  of  the  woman.  It  is  usually  anteflexed, 
but  when  the  woman  lies  on  her  back,  this  anteflexion  is  lessened  and  the 
uterus  falls  backward  on  to  the  vertebral  column.  When  the  woman 
stands  erect,  the  uterus  falls  forward,  increasing  the  anteflexion  and 
pushing  out  the  abdominal  wall,  so  that  it  becomes  much  more  prominent. 
As  it  lies  in  the  abdominal  cavity  it  is  twisted  on  its  longitudinal  axis, 
slightly  to  the  right,  so  that  its  left  border  becomes  more  anterior. 

This  lateral  torsion  is  easily  demionstrated  in  the  course  of  a  Cesarean 
section,  as  although  the  incision  is  made  in  the  median  line  of  the  abdomi- 
nal w^all,  the  incision  in  the  uterine  wall  lying  just  beneath  it  is  found 
to  be  much  nearer  the  left  than  the  right  uterine  cornu.  This  is  shown  in 
Fig.  170,  which  is  a  drawing  from  a  photograph  of  a  uterus  removed  by 
the  author  during  the  performance  of  a  Cesarean  section. 

The  Cervix. — The  cervix  at  the  end  of  pregnancy  shows  certain  changes 
due  to  the  increased  vascularity,  causing  an  increase  in  its  violet  hue  and 
a  greater  softening  in  its  structure.  Furthermore,  during  the  last  two 
weeks  of  pregnancy,  owing  both  to  this  increased  softening  and  to  the 
retraction  of  the  upper  part  of  the  cervix  into  the  lower  uterine  segment, 
there  appears  a  shortening  of  the  cervix  which  in  some  cases  is  very 
marked.  At  this  period,  moreover,  especially  in  multigravidse,  the 
cervical  canal  becomes  more  patulous. 

Soon  after  the  beginning  of  labor  an  interesting  change  may  be  noted 
in  the  uterine  wall.  The  upper  portion  contracts  more  vigorously 
and  becomes  thicker  than  the  lower  portion,  which  remains  nearly 
passive.  This  difference  in  behavior  divides  the  uterus  into  two  seg- 
ments which  have  already  been  referred  to  (see  page  210),  viz.,  the 
upper  and  lower  ute'rine  segments;  the  line  of  demarcation  between 
them  being  about  11  cm.  above  the  external  os,  at  the  line  of 
reflection  of  the  peritoneum  from  the  anterior  surface  of  the  uterus. 
Here  a  slight  contraction  ring,  known  as  Braune's  or  Bandl's  ring  may 
be  noted.    This  ring  and  the  difference  in  thickness  between  the  upper 


232  THE  MECHANISM  OF  LABOR 

and  lower  uterine  segments  becomes  more  marked  A\itli  the  progress 
of  labor,  especially  in  the  second  stage,  and  in  long  and  difficult  labors 
the  ring  often  stands  out  sharp  and  unyielding.  Below  the  ring  the  walls 
of  the  uterus  are  very  thin,  perhaps  about  1.5  mm.  in  thickness  and 
show  very  little,  if  any,  contractile  power,  thus  presenting  a  marked 
contrast  to  the  segment  above  the  ring,  which  is  thick  and  powerfully 
active,  Avith  walls  5-10  mm,  thick. 

The  origin  of  this  lower  uterine  segment  has  been  the  subject  of  much 
discussion.    Braune^  claimed  that  it  was  derived  entirely  from  the  cer- 


^M^' 

^s^ 


/      ; 


Fig.   170. — Uterus  removed  during  a  Cesarean  section,  showing  uterine  incision  nearer  k'ft 

cornu  than  right. 

vix,  and  that  the  ring  corresponded  with  the  internal  os.  If  this  is  so, 
the  cervix  must  change  greatly  in  length,  for  before  labor  it  is  only  3-4 
cm.  long,  and  Bandl's  ring  is  11  cm.  from  the  external  os.  The  other 
theory  is  that  the  upper  part  of  the  lower  uterine  segment  is  derived  from 
the  uterus  and  the  lower  3-4  cm.  is  derived  from  the  cervix. 

The  problem  is  not  easy  of  solution,  but  the  latter  theory  seems  to 
be  gaining  more  and  more  credence.    Williams,^  of  Baltimore,  describes 

*  Die  Lage  des  Uterus  und  Foetus  am  Ende  der  Schwangerschaft,  Leipzig,  1872. 
2  Obstetrics,  1908,  p.  239. 


THE  PARTURIENT  CANAL 


233 


a  section  of  the  lower  segment  taken  from  a  woman  who  died  m  premature 
labor,  in  which  for  3-4  cm.  above  the  external  os  the  lining  is  distinctly 
cervical  mucous  membrane,  while  above  this  the  tissue  is  uterine  in 
appearance  and  covered  by  decidua.  In  the  author's  specimen  (see  Fig. 
171)  microscopic  examination  under  a  high  power  shows  in  the  upper 
part  of  the  lower  uterine  segment,  structure  much  more  suggestive  of 
body  than  cervix  in  origin.    The  belief  that  the  lower  uterine  segment 


Fig.  171. — Uterus  removed  soon  after  labor,  showing  upper  and  lower  uterine  segments. 


is  derived  both  from  the  body  and  cervix  has  received  the  endorsement 
of  such  authorities  as  Schroeder,  Ruge,  Veit,  and  others. 

The  Vagina. — The  vagina  at  the  end  of  pregnancy  shows  an  increased 
vascularity.  It  is  bluish  in  color  and  the  secretion  from  its  glands  is 
much  increased.  The  discharge  is  thick,  whitish  in  color,  cheese-like 
in  consistency  and  acid  in  reaction.  It  is  composed  of  cast-off  epithelium 
and  contains  numerous  bacteria,  mostly  bacilli.  They  are  normally 
non-pathogenic,  and  indeed  the  normal  vaginal  secretion  possesses  bac- 
tericidal properties. 


234 


THE  MECHAXISM  OF  LABOR 


The  vajiimrl  walls  are  increased  slightly  in  length  so  that  a  slight 
fulness  of  the  tissues  is  often  observed  anteriorly — a  cystocele. 

\  iewed  as  a  whole  the  parturient  canal  may  be  looked  upon  as  com- 
posed of  three  divisions  (see  Fig.  172). 

1.  The  suprapelvic  division,  of  which  the  abdominal  wall  forms  the 
outer  coat  and  the  uterine  wall  the  inner  coat  and  together  they  serve 
as  a  propelling  force  as  well  as  a  part  of  the  parturient  canal. 

2.  The  pelvic  division,  of  which  the  bony  pelvis  with  its  mu.^cular 
and  fascial  lining  forms  the  outer  coat,  and  the  lower  uterine  segment 
and  the  vagina  the  inner  coat.  This  division  of  the  canal  being  passive 
in  labor  and  being  the  seat  of  most  of  the  resistance. 


Fk;.  11 


-Divisions  of  the  parturient  canal;  suprapelvic,  pelvic,  and  infrapeh-ic. 


3.  The  infrapelvic  division,  of  which  the  muscles  and  fascite  of  the 
pelvic  floor  form  the  outer  coat  and  the  vagina  the  inner  coat. 

This  division  is  also  resistant  in  action,  but  in  a  lesser  degree  than  the 
pelvic  division.  Its  chief  function  in  labor  seems  to  be  the  maintenance 
of  flexion  and  the  close  approximation  of  the  presenting  part  to  the 
pubic  arch. 

THE    FETUS    OR   PASSENGER. 

Considered  obstetrically,  the  head  is  the  most  important  part  of  the 
fetus,  as  it  is  the  hardest,  the  least  compressible,  and  usually  presents 
the  greatest  difficulty  in  delivery.  The  birth  of  the  body  is  usually 
simple  and  gives  but   little  trouble.     The  fetal  head  presents  certain 


THE  FETUS  OR  PASSENGER 


235 


characteristics  which  have  a  marked  influence  in  the  mechanism  of 
labor,  and  therefore  deserves  careful  consideration. 

It  is  made  up  of  two  parts:  the  face  and  the  cranium  (see  Fig.  173). 

The  Face. — The  bones  of  the  fetal  face  at  term  are  well  united  and 
the  face  as  a  whole  presents  but  slight  compressibility  compared  with 
the  cranium. 

However,  the  face  composes  but  a  small  part  of  the  head  and  the 
absence  of  teeth  and  the  shortness  and  obliquity  of  the  ramus  of  the 
inferior  maxilla  in  the  fetus  makes  the  fetal  face  relatively  much  smaller 
than  the  face  of  adult  life. 

The  Craniiim. — The  cranium  for  obstetri^cal  study  is  composed  of 
two  portions:  the  base,  which  is  hard  and'^'compressible,  with  bones 
firmly  united,  and  the  vault,  whose  bones  areseparated  from  each  other 
by  spaces  filled  with  membrane,  which  under  compression  allows  mold- 


FiG.   173. — The  fetal  head  and  its  diameters. 


ing  by  approximation  and  perhaps  overlapping  of  the  bones.  In  this 
way  the  diameters  of  the  fetal  head  are  reduced  and  the  large  cranium 
is  made  to  conform  to  the  shape  of  the  pelvic  canal,  the  compression 
occurring  over  the  hemispheres  of  the  fetal  brain  where  the  least  damage 
is  done. 

It  is  thus  seen  that  the  incompressible  portions  of  the  fetal  head  are 
the  face  and  the  base,  and  the  compressible  portion  is  the  vault. 

This  is  composed  of  the  two  frontal  bones,  the  two  parietal,  the 
wings  of  the  sphenoid,  the  two  temporal  bones,  and  the  upper  portion 
of  the  occipital  bone. 

Sutures. — In  the  adult  skull  the  different  bones  composing  it  are 
united  by  interlocking  dentated  processes  of  bone  called  sutures. 

In  the  face  and  base  of  the  fetal  skull  this  same  method  of  union  can 
be  seen,  but  in  the  compressible  fetal  vault  the  edges  of'  the  composing 


236 


THE  MECHANISM  OF  LABOR 


l)oiies  are  united  hy  inciiihraiie,  althougli  the  connection  is  still  called 
a  suture. 

Tlie  sutures  having  obstetrical  importance,  because  palpable  during 
labor  and  useful  in  diagnosis  of  the  position  of  the  fetal  head,  are  the 
lanibdoid  suture,  between  the  occipital  and  the  two  parietal  bones;  the 
sagittal,  between  the  parietal  bones;  the  coronal,  between  the  frontal 
and  parietal  bones;  and  the  frontal,  between  the  two  frontal  bones.  The 
other  sutures  are  usually  so  covered  by  soft  parts  or  so  distant  as  not  to 
be  palpable  through  the  cervix. 

Fontanelles. — Where  two  or  more  sutures  meet  together  leaving  an 
intervening  space  filled  with  membrane,  this  space  is  called  a  jontanelle. 
There  are  two  main  fontanelles  which  are  usually  present  in  every  fetal 
skull  and  utilized  in  diagnosis  of  position.  They  are  the  posterior  fon- 
tanelle  and  the  anterior  Jontanelle. 


Fig.  174. — The  posterior  fontanelle. 


Fig.   175. — The  anterior  fontanelle. 


The  posterior  fontanelle  (see  Fig.  174),  mentioned  first  because  the  one 
most  often  felt  in  a  normal  presentation,  is  that  at  the  junction  of  the 
sagittal  and  lambdoid  sutures;  it  is  triangular  in  shape,  bounded  by  the 
occipital  and  two  parietal  bones,  is  smaller  than  the  anterior  fontanelle, 
and  in  fact,  as  labor  advances,  may  be  practically  closed  by  the  lapping 
of  the  parietal  bones  over  the  occipital. 

The  anterior  fontanelle  (see  Fig.  175)  is  that  formed  at  the  junction 
of  the  coronal,  sagittal  and  frontal  sutures.  It  is  larger  than  the  posterior, 
is  quadrilateral  in  shape,  and  is  also  called  the  bregma. 

In  diagnosing  the  anterior  and  posterior  fontanelles  it  is  evident  from 
the  above  that,  aside  from  the  difference  in  size,  the  anterior  fontanelle 
has  four  lines  of  sutures  running  into  it,  while  the  posterior  has  only  three. 


THE  FETUS  OR  PASSENGER 


237 


The  posterior  fontanelle  usually  closes  within  a  few  months  after 
birth,  while  the  anterior  may  remain  open  during  the  first  year,  and  in 
rare  instances  even  beyond  the  second  year.  Of  less  obstetrical  impor- 
tance, because  not  palpable,  save  in  marked  lateral  obliquity  of  the  fetal 
head,  are  two  fontanelles  of  irregular  shape,  called  the  temporal  fon- 
tanelles,  found  at  the  anterior  and  posterior  extremity  of  each  parietal 
bone  where  it  joins  the  temporal. 

Occasionally  on  account  of  faulty  ossification  a  fontanelle  is  found  in 
the  sagittal  suture  about  midway  between  the  anterior  and  posterior 
fontanelles.  It  is  called  the  sagittal  fontanelle  and  resembles  the  anterior 
fontanelle  in  shape  but  is  usually  smaller  in  size. 

Articulation. — A  lateral  view  of  a  fetal  skeleton  (see  Fig.  176)  shows 
that  the  occipito-atloid  articulation  (B)  is  much  nearer  the  occipital  pro- 


FiG.   176. — Articulation  of  the  fetal  head. 

tuberance  (C)  than  it  is  to  the  mental  process  of  the  inferior  maxillary 
bone  (.4),  i.  e.,  the  articulation  between  the  head  and  spinal  column  is 
posterior  to  the  centre  of  the  head  (E,  D).  As  the  anterior  arm  of  the 
lever  (distance  between  articulation  and  chin)  is  greater  than  the  pos- 
terior arm  (distance  between  articulation  and  occipital  protuberance) 
pressure  on  the  vault  of  the  craniimi  at  its  centre  or  am-uhere  in  front 
of  it  tends  to  make  the  chin  approach  the  sternum,  a  motion  which  is 
called  flexion.  :Moreover,  even  if  the  pressure  was  evenly  distributed 
over  the  cranial  vault,  as  more  of  the  vault  lies  in  front  of  than  behind 
the  line  of  articulation  with  the  spine,  flexion  would  normally  result. 
Hence  the  frequency  of  flexion,  as  the  normal  attitude  of  the  fetal  head, 
produced  by  the  resistance  of  the  pelvic  canal  to  the  advance  of  the 
fetus,  with  its  accompanying  pressure  on  the  vault  of  the  fetal  craniimi. 


238 


THE   MECHAXISM  OF  LABOR 


Motions  of  the  Fetal  Head. — It  is  well  in  this  connection  to  study  the 
different  motions  oi  the  fetal  head  upon  the  spinal  column.  The  most 
frequent  (flexion)  has  just  been  considered  and  may  be  defined  as  follows: 
P'lexion  of  the  head  is  a  motion  on  its  transverse  axis  b\'  which  the  chin 
approaches  the  sternum.  It  takes  place  chiefly  in  the  occipito-atloid 
articulation,  although  it  may  be  increased  by  a  forward  bending  in  the 
cervical  spine.  Lateral  flexion  of  the  head  is  a  motion  on  its  antero- 
posterior axis,  by  which  one  parietal  eminence  approaches  the  shoulder 
of  that  side.  A  certain  amount  of  lateral  flexion  is  possible  at  the  occipito- 
atloid  articulation;  a  continuance  of  it  is  produced  by  a  lateral  bending 
of  the  whole  of  the  cervical  portion  of  the  spine. 

Extension. — Extension  of  the  head  is  a  motion  on  its  transverse  axis 
by  which  the  chin  recedes  from  the  sternum.    This  motion  takes  place 

at  the  occipito-atloid  articulation,  and 
is  produced  in  one  of  two  ways:  either 
(1)  by  greater  pressure  being  applied 
to  the  vault  of  the  cranium  behind  the 
line  of  the  spinal  articulation  than  is 
applied  in  front  of  it,  or  (2)  an  obstacle 
to  flexion  being  present,  pressure  ap- 
plied even  in  front  of  the  line  of  spinal 
articulation  may  cause  recession  of  the 
chin  from  the  sternum. 

Rotation. — Rotation  of  the  head  is 
a  motion  on  its  vertical  axis  by  which 
the  chin  approaches  the  line  of  either 
shoulder.  This  motion  begins  at  the 
atlo-axoid  articulation  and  is  continued 
by  a  rotation  of  the  cervical  portion 
of  the  spinal  column. 

Diameters  of   the   Fetal  Head. — P'or 

the  comparison  of  the  shape  and  size 

of  the  child's  head  with  the  shape  and 

size  of  the  pelvic  canal  through  which 

it  has  passed,  the  postpartum  measurements  are  taken  of  various  diameters 

of  the  fetal  head.     At  the  Sloane  Hospital  it  is  the  routine  custom  to 

measure  the  following  cephalic  diameters  (see  Figs,  173  and  177). 

The  Suboccipitobregntatic. — The  distance  from  a  point  on  the  under 
surface  of  the  occipital  bone  where  it  joins  the  neck  to  the  middle  of  the 
anterior  fontanelle. 

The  Snboccipitofronfal. — The  distance  from  the  same  point  behind 
to  the  root  of  the  nose  in  front. 

The  Occipitofrontal. — The  distance  from  the  most  prominent  part 
of  the  occipital  bone  to  the  root  of  the  nose. 

The  Occipitomental. — The  distance  from  the  most  prominent  part  of 
the  occiput  to  the  most  prominent  part  of  the  chin. 

The  Bijjarietal. —The  greatest  distance  between  the  two  parietal 
eminences. 


Fig.   177. — Biparietal  diameter. 


THE  FETUS  OR  PASSENGER  239 

In  addition  to  these  cephalic  diameters  it  is  the  custom  to  take  the 
diameter  of  the  shoulders,  called  the  hisacromial — the  greatest  distance 
between  the  two  acromial  processes. 

The  measurement  immediately  after  birth  of  the  heads  of  100  children 
born  at  the  Sloane  Hospital,  w^th  presentation  other  than  breech,  and 
of  100  children  born  with  breech  presentation,  gave  the  following  average 
diameters : 

Presentation  other  Breech 

Diameters.  than  breech.  presentation. 

Suboceipitobregmatic 9.4250  cm.  9.6250  cm. 

Suboccipitofrontal 10.2830  cm.  10,7895  cm. 

Occipitofrontal 11.4750  cm.  11.5300  cm. 

Occipitomental 13.2205  cm.  12.7600  cm. 

Biparietal 9.2270  cm.  9.6100  cm. 

Bisacromial 12.4225  cm.  12.5300  cm. 

The  measurement  immediately  after  birth  of  another  series  of  100 
children  without  regard  to  the  presentation  and  omitting  small  fractions 
gave  the  following  average  diameters: 

Suboceipitobregmatic 9.50  cm. 

Suboccipitofrontal 10.50  cm. 

Occipitofrontal 11.50  cm. 

Occipitomental 13 .  25  cm. 

Biparietal 9.25  cm. 

Bisacromial       .      .      .      .' 12.25  cm. 

It  is  the  custom  of  the  author  to  regard  these  measurements  as  the 
average  diameters  of  the  fetal  head. 

In  addition  to  the  above  diameters  it  is  the  custom  at  the  Sloane 
Hospital  to  measure  the  following  circumferences  and  the  length  of  the 
child  at  birth. 

Circumferences. — The  suhoccijntofrontal,  taken  in  the  plane  of  the  sub- 
occipitofrontal diameter. 

The  occipitofrontal,  taken  in  the  plane  of  the  occipitofrontal  diameter 
— the  largest  cephalic  diameter  thrown  across  the  pelvis  (save  perhaps 
in  brow  presentation). 

The  hisacromial,  taken  in  the  plane  of  the  bisacromial  diameter. 

The  measurement  immediately  after  birth  of  a  series  of  100  children 
with  presentation  other  than  breech,  and  a  series  of  100  children  with 
breech  presentation,  gave  the  following  average  circumferences: 

Fetal  Circumferences. 

Presentations  other  Breech 

than  breech.  presentation. 

Suboccipitofrontal 32.455  cm.  34.3050  cm. 

Occipitofrontal 34.515  cm.  34.9275  cm-. 

Bisacromial 35.880  cm.  36.2950  cm. 

For  practical  purposes  not  regarding  the  presentation  of  the  fetus 
the  following  may  be  considered  the  average  circumferences : 

Suboccipitofrontal 33 . 0  cm. 

Occipitofrontal 34.5  cm. 

Bisacromial 36.0  cm. 


240 


THE  MECHANISM  OF  LABOR 


Length  of  the  Child. — The  measurement  of  the  length  of  several 
thousand  children  at  birth  gave  the  average  length  of  the  normal  child 
at  full  term  as  50  cm.  or  20  inches. 


Fig.   178. — Parietal  bones  overlapping  the  occipital  and  the  frontal  bones. 

Molding. — ^Although  the  above  are  given  as  the  average  measure- 
ments of  the  fetal  head,  it  must  be  noted  that  by  a  wise  provision  of 
nature  these  measurements  may  be  greatly  changed  under  pressure, 
and  the  various  diameters  altered  to  meet  the  demands  of  the  individual 
parturient  canal  without  injury  to  the  fetus.  Thus  the  bones  of  the 
cranial  vault  being  united  by  membranous  sutures,  and  being  more  or 


1  Fig.   179.— One  parietal  bone  overlapping  the  other. 

less  pliable  in  themselves,  may  allow  reduction  in  the  cephalic  diameters 
in  one  of  two  ways:  either  (1)  by  approximation  and  o^•erlapping  of 
opposing  bones,  or  (2)  by  bending  of  the  pliable  individual  bones.     A 


THE  PROPELLING  FORCE  241 

certaiD  rule  ma}'  be  noted  in  the  overlapping  of  cranial  bones.  Thus 
the  parietal  bones  usually  overlap  the  occipital  and  the  frontal  bones 
rather  than  vice  versa  (see  Fig.  178).  Furthermore,  one  parietal  may 
overlap  the  other  (see  Figs.  179). 

The  diameters  of  the  fetal  head  may  be  further  reduced  by  compression 
of  its  contents;  some  of  the  cerebral  fluid  being  expressed  into  the  spinal 
canal  and  some  of  the  blood  being  forced  out  of  the  cerebral  vessels,  all 
of  this  being  only  temporary  and  usually  without  injury  to  the  child. 

As  a  result  of  this  molding,  however,  the  shape  of  the  child's  head 
at  birth  and  the  expression  of  its  features  are  sometimes  a  disappoint- 
ment to  the  parents,  and  require  for  their  peace  of  mind  the  assurance 
by  the  obstetrician  that  the  disfigurement  is  only  temporary  and  will 
all  disappear  in  a  day  or  two. 

THE   PROPELLING   FORCE. 

The  forces  concerned  in  the  expulsion  of  the  child  are  two:  (1)  the 
uterine;    (2)  the  ahdominal  ivall. 

The  Uterine  Force. — The  uterine  force  is  rhythmical,  intermittent  and 
involuntary.  It  is  rhythmical  in  the  sense  that  there  is  an  approximate 
regularity  in  the  recurrence  of  the  uterine  contractions;  the  interval 
between  these  contractions,  however,  varies  greatly  in  the  different  stages 
of  the  labor.  Thus  in  the  early  part  of  the  first  stage  there  may  be  an 
interval  of  thirty  minutes,  while  in  the  latter  part  of  the  second  stage 
the  contractions  may  be  separated  by  only  two  or  three  minutes.  It 
is  fortunate,  alike  for  mother  and  child,  that  the  contractions  are  intermit- 
tent. The  woman  could  not  endure  the  continuous  suffering  of  unin- 
terrupted uterine  contractions.  The  wise  provision  of  nature  for  the 
maintenance  of  the  strength  of  the  patient,  by  the  intervening  periods 
of  rest,  is  now^here  seen  to  better  advantage  than  in  the  intermittent 
character  of  uterine  contractions.  Furthermore,  but  for  these  periods 
of  relaxation,  the  uterine  muscle  would  lose  its  vitality  and  sloughing 
would  result.  Rupture  of  the  uterus  also,  the  result  feared  in  all  cases 
of  tonic  uterus,  would  be  more  frequent.  Moreover,  in  the  interest  of 
the  fetus,  intermissions  in  the  contractions  of  the  uterus  are  absolutely 
essential,  as  otherwise  the  uteroplacental  circulation  would  be  impeded, 
and  asph\':sia  of  the  fetus  would  result. 

The  length  of  time  occupied  by  a  uterine  contraction  varies  according 
to  the  stage  of  labor.  In  the  first  stage  the  contraction  usually  lasts 
onl}^  about  half  a  minute,  while  in  the  second  stage  it  may  last  a  minute 
or  more. 

The  uterine  contractions  are  involuntary,  as  is  shown  by  their  con- 
tinuance when  the  patient  is  under  the  influence  of  an  anesthetic,  or  as 
is  occasionally  seen  in  cases  of  spinal  paralysis. 

The  effect  of  the  uterine  contractions  varies  in  the  stages  of  labor. 
In  the  first  stage,  before  the  rupture  of  the  membranes,  the  force  of  the 
contraction  is  spent  chiefly  in  bringing  about  the  dilatation  of  the  cervix, 
and  but  little  in  causing  descent  of  the  presenting  part. 
16 


242  THE  MECHANISM  OF  LABOR 

It  causes  the  dilatation  of  the  cer\ix  by  retraction  of  the  muscular 
structure  from  the  lower  toward  the  upper  uterine  segment,  and  by 
forcing  downward  the  fluid  wedge  produced  by  the  distention  of  that 
portion  of  the  amniotic  sac  which  lies  over  the  internal  os  with  the 
liquor  amnii  lying  in  front  of  the  presenting  part. 

After  the  rupture  of  the  membranes  the  force  of  the  uterine  contrac- 
tions causes  a  further  retraction  of  the  ce^^'ix  toward  the  upper  uterine 
segment,  and  continues  the  dilatation  of  the  cervix  by  forcing  downward 
the  solid  wedge  of  the  presenting  part. 

During  the  second  stage  the  uterine  contractions  })ring  about  descent 
of  the  fetus,  both  by  direct  rlownward  pressure  of  the  fundus  upon  the 
fetal  trunk  and  also  by  indirect  fluid  pressure  upon  the  fetus,  where  only 
a  small  amount  of  liquor  amnii  has  escaped  and  more  or  less  of  the  fetus 
is  surrounded  by  it. 

The  Abdominal  Wall  Force. — The  abdominal  wall  force  comprises 
the  action  both  of  the  diaphragm  and  of  the  muscles  of  the  anterior  and 
lateral  portions  of  the  abdominal  wall.  That  the  force  of  these  muscles 
is  not  absolutely  essential  to  the  birth  of  the  child  in  many  instances 
can  be  easily  demonstrated  in  cases  deeply  anesthetized.  That  the 
abdominal  force  greatly  assists  and  accelerates  the  progress  of  labor  is 
often  seen  when  the  patient,  after  a  little  instruction  and  encouragement, 
brings  into  play  her  abdominal  muscles,  which  up  to  that  time  she  had 
not  employed.  During  the  first  part  of  the  second  stage  the  force  of 
the  abdominal  muscles  is  largely  voluntary  and  may  be  used  or  not  at 
will.  In  the  latter  part  of  this  stage,  however,  when  the  presenting  part 
rests  upon  the  pelvic  floor,  the  action  of  the  abdominal  muscles  is  prac- 
tically involuntary.  It  is  very  difficult  to  accurately  determine  the 
amount  of  the  propelling  force  in  the  synchronous  contraction  of  the 
uterine  and  abdominal  muscles.  It  is  variously  estimated  at  from 
40  to  100  pounds. 

Schatz^  inserted  into  the  uterus  a  rubber  bag  connected  with  a  man- 
ometer. He  found  that  the  force  of  the  pains  varied  from  8^  to  27^  pounds, 
increasing  as  the  head  reached  the  perineiun. 

Joulin-  tried  to  estimate  the  force  b\'  using  forceps  to  which  was 
attached  a  dynamometer  which  recorded  the  amount  of  traction  neces- 
sary to  deliver  the  fetus.  This  varied  from  80  to  100  pounds.  Neither 
of  these  methods  would  seem  to  be  very  accurate.  Every  obstetrician 
has  some  idea  of  the  force  required  to  prevent  the  head  coming  over 
the  perineum  too  rapidly,  and  often  roughly  estimates  it  at  about  50 
pounds,  although  of  course  this  is  only  approximate. 

The  force  undoubtedly  varies  with  the  strength  and  posture  of  the 
woman.  In  the  squatting  posture  the  force  would  be  greatest,  while 
in  the  lateral  or  semiprone  position  it  would  be  least.  When  the  head 
is  passing  over  the  perineum  the  expulsive  force  is  often  diminished. 

1  Uel>er  die  Eutwickelung  der  Kraft  des  Uterus  im  Verlaufe  dcr  Geburt,  Verb.  d.  deutschen 
GeseU.  fiir.  Gyn..  1895.  vl,  5.31-.542. 

*  Mcmoire  sur  I'cmploi  de  la  force  in  obstetri(jue,  Arch.  gen.  de  med.  fev.  et  mars,  1867, 
i,  149,  .313. 


ATTITUDE— PRESENTATION— POSITION  243 

This  is  due  to  the  fact  that  the  excessive  pain  from  the  stretching  and 
tearing  of  the  soft  parts,  causes  the  woman  to  cry  out — "the  perineal 
cry" — thus  releasing  the  diaphragm "  and  nullifying  the  contractions  of 
the  abdominal  muscles.  Thus  does  nature  by  this  wise  provision  tend  to 
save  the  perineimi.  Anesthesia  given  at  this  stage  has  t^e  double  advan- 
tage of  lessening  the  muscular  contractions  and  of  diminishing  the  suffer- 
ings of  the  woman. 

Aside  from  the  expulsive  forces  of  the  uterus  and  abdominal  wall, 
a  third  factor  enters  into  the  descent  of  the  fetus  in  the  pelvic  canal, 
viz.,  the  straightening  out  of  the  body  of  the  fetus,  caused  by  the  uterine 
contractions  during  the  second  stage.  Schroeder  estimates  this  increase 
in  length  of  the  fetus  as  5.5  cm.,  and  Olshausen,  as  7.2  to  10  cm.  This 
is  seen  especially  in  vertex  cases  where,  with  the  fundus  steadying  the 
breech,  the  increase  in  the  length  of  the  fetal  ovoid  causes  descent  of 
the  head  in  the  pelvis.  During  the  first  stage  it  is  probable  that  the 
position  of  the  fetus  changes  but  little.  It  must  be  remembered  that  in 
many  cases  before  labor  the  fetus  with  the  uterus  has  settled  into  the 
pelvis  so  that  the  biparietal  diameter  is  on  a  level  with  the  ischial  spines. 
This  is  generally  true  in  prunigravidse,  while  in  multigravidae,  on  the 
other  hand,  the  head  may  remain  at  the  brim  until  the  beginning  of  the 
second  stage  of  labor.  In  the  second  stage,  with  the  presenting  part 
resting  on  the  pelvic  floor,  over  half  of  the  fetal  body  is  below  the  con- 
traction ring,  and  the  uterine  contractions  are  acting  upon  the  upper 
part  of  the  fetal  ovoid  alone,  pushing  it  downward  and  outward.  Fur- 
thermore, pressure  of  the  presenting  part  upon  the  pelvic  floor  tends  to 
stimulate  contractions  of  the  diaphragm  and  the  abdominal  wall  and 
the  expulsive  force  is  now  the  greatest.  The  relation  of  the  different 
parts  of  the  fetus  to  each  other  and  to  the  parturient  canal  may  next 
be  studied  with  advantage  and  under  three  heads. 

ATTITUDE.     PRESENTATION.     POSITION. 

Attitude. — The  attitude  of  the  fetus  is  the  relation  which  different 
parts  of  its  body  bear  to  one  another,  irrespective  of  the  presentation 
or  position.  The  attitude  which  the  fetus  normally  assumes  in  the 
uterus  (see  Fig.  180)  is  one  of  universal  flexion — the  back  curved  forward; 
the  chin  on  the  sternum;  the  arms  and  legs  sharply  flexed  and  close 
to  the  body,  with  the  hands  and  feet  respectively  crossing  each  other, 
the  feet  being  turned  in. 

The  umbilical  cord  lies  between  the  thighs.  In  this  attitude  the  fetus 
occupies  the  least  possible  space.  This  attitude  gives  the  fetus  some- 
what the  shape  of  an  egg,  and  for  this  reason  it  is  often  spoken  of  as  the 
"fetal  ovoid."  It  must  be  noted,  however,  that  only  one  side  (the  back) 
is  convex,  while  the  opposite  side,  the  abdominal,  is  concave.  One  end 
of  the  fetal  ovoid  is  called  the  cephalic,  and  the  other  the  pehic,  corre- 
sponding respectively  to  the  head  and  the  buttocks. 

The  attitude  of  universal  flexion  is  the  normal  one,  for  in  this  attitude, 
whether  the  cephalic  or  the  pelvic  end  of  the  fetal  ovoid  presents,  labor 


244 


THE  MECHANISM  OF  LABOR 


is  easiest.  Any  variation  from  this  attitude  is  abnormal  and  usually 
makes  labor  more  difficult. 

Presentation. — Presentation  is  a  term  used  to  denote  the  relation 
which  the  long  axis  of  the  fetus  bears  to  that  of  the  mother.  When  these 
axes  coincide  the  presentation  may  be  said  to  be  longifinlinal,  while  if 
there  is  a  marked  variatio  nbetween  them  it  is  called  (ihliqiie  or  iransxersc 

Oblique  Presentations. — Oblique  presentations  are  of  little  importance, 
as  they  tend  to  become  either  longitudinal  or  transverse. 

Longitudinal  Presentations. — Longitudinal  ]:)resentations  are  divided 
into  two:  the  cephalic  and  pelvic,  according  to  the  end  of  the  fetal  o\'oid, 


Fig.   ISO. — The  attitude  of  universal  flexion. 


which  lies  at  the  brim  of  the  pelvis  and  can  be  felt  by  the  examining 
fingers.  Longitudinal  presentations  are,  as  a  rule,  favorable  presentations, 
while  transverse  presentations  are  unfavorable,  as  they  generally  neces- 
sitate interference  on  the  part  of  the  obstetrician.  Fortunately  over  99 
per  cent,  of  all  presentations  are  longitudinal.  In  20,()()()  consecutive 
labors  in  the  author's  service  at  the  Sloane  Hospital,  99.1  per  cent, 
were  longitudinal  presentations. 

The  term  "presenting  part,"  often  employed,  refers  to  that  i)()rtion 
of  the  fetus  which  lies  over  the  cervix  and  is  felt  through  the  vagina  by 
the  examining  fingers.  By  distinguishing  the  presenting  part  we  are 
enabled  to  divide  presentations  more  accurately.     Thus  in  cephalic  pre- 


ATTITUDE— PRESENTATION— POSITION 


24^ 


sentations  with  the  head  well  flexed   (the  normal  attitude),  the  vertex 
lies  over  the  cervix  and  w^e  have  a  vertex  presentation  (see  Fig.  181). 


Fia.   181. — Vertex  presentation 


Fig.  182. — Bregma  presentation. 


246 


THE  MECHANISM  OF  LABOR 


When  the  head  is  slightly  extended,  the  large  fontanelle  or  bregma  is 
the  presenting  part — a  bregma  presentation  (see  Fig.  182).  ^Yhen 
the  head  is  more  extended  we  have  a  brow  presentation  (see  Fig.  183). 


Fig.  183. — Brow  presentation 


Fig.  184  — Face  presentation. 


ATTITUDE— PRESENTATION— POSITION 


247 


With  the  head  in  extreme  extension  the  face  lies  over  the  cervix — a  face 
presentation  (see  Fig.  184). 

In  pelvic  presentations  the  breech  lies  over  the  cervix  and  is  the  pre- 
senting part,  hence  the  name  breech  presentation.  When  the  legs  are 
flexed  upon  the  thighs  and  upon  the  abdomen,  the  presentation  is  called 
a  "normal"  or  "complete"  breech  presentation  (see  Fig.  185).  At 
times,  however,  the  fetus  lies  in  an  abnormal  attitude,  with  the  legs 
extended  straight  along  its  body,  the  feet  near  the  upper  part  of  the 
chest.     This  is  called  a  "frank"  or  "incomplete  breech"  presentation 


Fig.   185. — Normal  or  complete  breech  presentation. 


or  a  "breech  with  extended  legs"  (see  Fig.  186).  At  times  the  foot  or 
knee  may  lie  over  the  cervix  giving  a  "foot"  or  "knee  presentation." 
These  last  two  are  of  little  importance  as  the  prognosis  and  treatment 
differs  but  little  from  that  of  the  normal  breech  presentation.  The 
two  important  varieties  are  the  "complete"  and  the  "frank"  breech 
presentations  just  described. 

In  transverse  presentations,  while  either  the  shoulder,  the  hip  or  any 
portion  of  the  trunk  may  at  first  lie  over  the  cervix  at  the  brim  of  the 
pelvis,  as  the  labor  progresses  these  other  parts  usually  change  into 


248  THE  MECHANISM  OF  LABOR 

presentation  of  one  or  other  shoulder  so  that  transverse  prcsentadon  is 
usually  regarded  as  synonymous  with  shoulder  presentation. 

The  hand  or  elbow  may  be  the  presenting  part,  but  this  is  extremely 
rare  except  in  transverse  presentations  and  here  the  prolapse  of  the 
upper  extremity  does  not  materially  alter  either  the  prognosis  or  the 
treatment.  The  separate  nomenclature  of  hand  presentation  and  elbow 
presentation  is  little  employed. 


^'- 


^      \ 


^ 


7      '^    ^ 

Fig.  186. — Frank  breech  presentation. 

A  Compound  Presentation. — A  compound  presentation  is  one  in  which 
there  is  a  prolapse  into  the  peh'is  of  one  or  both  of  either  the  upper  or 
lower  extremities  alongside  of  the  presenting  part.  Thus  there  may  be 
various  combinations  in  the  presentation,  as  the  head  and  a  hand,  or 
the  head  and  both  hands,  or  the  head  and  a  hand  and  a  foot,  etc.  It 
will  be  noted  that  the  chief  presenting  part  in  these  cases  is  usualh'  the 
head. 

Position. — The  position  of  a  fetus  is  the  relation  of  a  selected  portion 
of  the  presenting  part  to  certain  fixed  landmarks  in  the  maternal  pelvis. 
In  a  vertex  presentation  the  selected  portion  of  the  presenting  part  is 


ATTITUDE— PRESENTA  TION— POSITION  249 

the  occiput;  in  a  breech  presentation  it  is  the  sacrum;  in  a  face  presen- 
tation it  is  the  chin. 

The  fixed  landmarks  in  the  pelvis  to  which  reference  has  been  made  are 
the  sacro-iliac  joints  behind  and  the  iliopectineal  eminences  in  front. 

It  is  evident  that  the  selected  portion  of  the  presenting  part  may 
assume  any  position  in  the  circle  of  the  pelvic  cavity,  but  only  eight  are 
considered:  four  primary  and  important,  and  four  secondary  or  tran- 
sitional and  of  less  importance.  The  four  primary  positions  are  deter- 
mined by  the  relation  of  the  selected  portion  of  the  presenting  part  to 
the  four  fixed  landmarks  already  mentioned  which  lie  at  the  extremities 
of  the  right  and  left  pelvic  diameters,  as  for  instance,  in  a  vertex  presen- 
tation, the  four  primary  positions  are: 

1 .  Occiput  opposite  left  iliopectineal  eminence. 

2.  Occiput  opposite  right  iliopectineal  eminence. 

3.  Occiput  opposite  right  sacro-iliac  joint. 

4.  Occiput  opposite  left  sacro-iliac  joint. 

In  addition  to  these  primary  positions  there  are  four  of  less  impor- 
tance in  which  the  selected  portion  of  the  presenting  part  lies  in  the 
pelvis  at  points  which  are  midway  between  the  four  landmarks  above 
mentioned.  Thus  in  a  vertex  presentation  the  occiput  may  lie  directly 
anterior  or  directly  posterior,  directly  to  the  left  or  directly  to  the  right. 

It  is  customary  to  abbreviate  thus: 

O — occiput;  M — chin  (from  mentum) ;  S — sacrum;  L — left;  R — aright; 
A — anterior;  P— posterior. 

In  a  vertex  presentation  then  the  eight  positions  may  be  summarized 
as  follows: 

Positions  of  a  Vertex  Presentation. — Left  occipito-anterior — L.  O.  A. — 
occiput  at  left  iliopectineal  eminence.  Right  occipito-anterior — R.  O.  A. — 
occiput  at  right  iliopectineal  eminence.  Right  occipitoposterior^R.  0. 
P. — occiput  at  right  sacro-iliac  joint.  Left  occipitoposterior — L.  O.  P. — 
occiput  at  left  sacro-iliac  joint.  Occiput  anterior — O.  A. — occiput 
directly  anterior.  Occiput  posterior — O.  P. — occiput  directly  posterior. 
Occiput  left — ^L.  O. — occiput  directly  to  left.  Occiput  right — R.  O. 
— occiput  directly  to  right. 

In  face  presentation,  substituting  chin  for  occiput,  we  derive  eight 
similar  positions,  thus: 

Positions  of  Face  Presentation.^ — ^Left  mento-anterior — L.  M.  A. — chin 
at  left  iliopectineal  eminence.  Right  mento-anterior — R.  M.  A. — chin 
at  right  iliopectineal  eminence.  Right  mentoposterior — R.  M.  P. — chin 
at  right  sacro-iliac  joint.  Left  mentoposterior — ^L.  M.  P. — chin  at  left 
sacro-iliac  joint.  Mento-anterior — M.  A. — chin  directly  anterior. 
Mentoposterior — ^M.  P. — chin  directly  posterior.  Mentoleft — L.  M. 
— chin  directly  to  left.    Mentoright — R.  M. — chin  directly  to  right. 

1  It  would,  of  course,  be  more  consistent  when  speaking  of  positions  of  the  chin  to  use 
the  initial  "C"  rather  than  "M"  as  the  abbreviation  for  chin,  while  the  English  woids 
right  and  left  are  used;  or  else  to  use  the  Latin  words  Dextra  and  Sinistra  with  abbrevia- 
tions "D"  and  "S";  but  the  abbreviation  "M"  has  so  long  been  in  general  use  with  the 
English  words  right  and  left,  that  it  has  been  decided  to  retain  this  nomenclature. 


250  THE  MECHANISM  OF  LABOR 

In  breech  presentations,  substituting  sacrum  for  occiput,  eight  similar 
positions  are  possible,  thus: 

Positions  of  Breech  Presentation.^ — Left  sacro-anterior — L.  S.  A. — sacrum 
at  left  iliopectineal  eminence.  Right  sacro-anterior — R.  S.  A. — sacrum 
at  right  iliopectineal  eminence.  Right  sacroposterior — R.  S.  P. — sacrum 
at  right  sacro-iliac  joint.  Left  sacroposterior — L.  S.  P. — sacrum  at  left 
sacro-iliac  joint.  Sacro-anterior — S.  A. — sacrum  directly  anterior. 
Sacroposterior^ — S.  P. — sacrum  directly  posterior.  Sacro-Ieft — L.  S. 
— sacrum  directly  to  left.    Sacro-right — R.  S. — sacrum  directly  to  right. 

Brow  and  bregma  (also  called  sincipital)  presentations  are  transitional 
presentations  only  and  it  is  therefore  unnecessary  to  tabulate  the 
eight  possible  positions  of  each  of  them.  This,  however,  may  easily  be 
done  if  desired. 

By  the  three  letters  used  in  the  abbreviation  are  indicated  at  once  the 
presentation,  the  position  and  the  attitude  of  the  fetus.  Thus  L.  O.  A.: 
the  presentation  is  a  vertex,  the  position  is  that  with  occiput  at  the  left 
iliopectineal  eminence,  and  the  attitude  is  one  of  flexion. 

As  has  been  said,  longitudinal  presentations  occur  in  over  99  per  cent, 
of  all  cases.  This  great  predominance  is  very  fortunate,  and  can  easily 
be  explained  by  the  fact  that  the  long  diameter  of  the  fetus  naturally 
seeks  the  long  diameter  of  the  uterus.  The  uterus  being  a  muscular 
structure,  relaxing  and  contracting  throughout  pregnancy,  and  the 
fetus  being  freely  suspended  in  the  liquor  amnii  within  it,  make  this  the 
more  reasonable;  for  if  the  fetus  for  any  reason  becomes  obliquely  or 
transversely  placed,  the  wall  of  the  uterus  is  put  on  the  stretch,  and  con- 
tractions occur  which  turn  the  fetus  back  into  the  longitudinal  diameter. 

Cephalic  presentations  predominate  greatly  over  pelvic.  Li  a  con- 
secutive series  of  20,252  births  at  the  Sloane  Hospital,  95  per  cent,  were 
cephalic  presentations  4.12  per  cent,  were  breech,  0.17  per  cent,  were 
brow,  0.38  per  cent,  were  face,  and  0.89  per  cent,  were  transverse  pre- 
sentations. 

Schroeder,^  from  a  study  of  several  hundred  thousand  cases,  gives 
the  percentage  of  vertex  presentations  as  95  per  cent. ;  face  presentations, 
0.6  per  cent.;  breech,  3.11  percent.;  and  transverse  presentations  as  0.56 
per  cent. 

Pinard^  gives  statistics  very  similar  (95.5  per  cent.,  0.4  per  cent.,  3.3 
per  cent,   and  0.8  per  cent.). 

If  only  labor  at  term  is  considered,  there  is  a  still  greater  predominance 
of  vertex  presentations,  96.97  per  cent.,  while  breech  presentations  occur 
only  in  1.77  per  cent. 

Thus  it  is  seen  that  in  the  vast  majority  of  cases,  nature  causes  a 
cephalic  presentation,  which  is  usually  the  most  favorable  for  both  mother 
and  child.  IVIuch  has  been  written  and  many  experiments  have  been 
performed  to  find  the  cause  for  this  predominance  of  cephalic  presenta- 
tions. 

The  gravitation  theory  has  been  thought  by  some  to  explain  it. 

1  Lehrbuch  der  Geburtshiilfe,  xiii,  Aufl.,  1899. 

*  L'acCommodation  foetale.    Traite  du  palper  abdominal,  Paris,  1878,  2me  ed,  1889. 


MECHANISM  OF  LABOR  IN   VERTEX  PRESENTATION        251 

This  resulted  from  the  following  experiment:  A  dead  fetus  was  sus- 
pended in  a  salt  solution  of  a  specific  gravity  equal  to  that  of  the  fetus 
(1.050-1.055),  when  it  was  found  that  the  head  and  right  side  sank  down- 
ward (Duncan/  Veit^).  It  was  shown  later,  however,  that  when  the 
specific  gravity  of  the  fluid  was  the  same  as  that  of  normal  liquor  amnii 
(1.008-1.009)  the  breech  always  sank  first  (Schatz,^  confirmed  by 
Williams'^).  Therefore  the  gravitation  theory  does  not  seem  satisfactory. 
The  most  generally  accepted  theory  to  account  for  the  predominance 
of  cephalic  presentation  is  the  "accommodation  theory." 

According  to  the  above  the  fetus  best  fits  the  cavity  of  the  uterus  when 
it  lies  with  the  head  down  and  if  it  be  turned  to  any  other  presentation 
so  that  the  breech  is  down,  or  the  body  is  transverse  or  oblique,  the 
uterus  by  its  contractions  will  usually  turn  the  fetus  back  to  the  position 
with  the  head  below.  Moreover,  in  conditions  where  the  fetus  does  not 
fit  the  cavity  of  the  uterus,  such  as  in  prematurity,  excessive  liquor 
amnii,  twin  pregnancies,  monstrosities,  tumors,  etc.,  abnormal  presenta- 
tions such  as  breech  or  transverse  may  result.  This  theory  seems  to  be 
borne  out  by  facts;  the  upper  part  of  the  uterine  cavity  is  more  roomy 
than  the  lower,  while  the  breech  with  the  thighs  and  legs  is  more  bulky 
(though  more  compressible)  than  the  head.  Thus  the  fetus  fits  the 
uterine  cavity  best  in  cephalic  presentations  and  is  usually  found  (95 
per  cent,  of  cases)  with  head  downward.  It  is  in  the  birth  of  the  head, 
however,  that  the  greatest  difficulty  lies,  for  this  is  the  largest  and  least 
compressible  part  of  the  fetus.  The  birth  of  the  body  is  usually  simple 
and  gives  little  difficulty. 


MECHANISM   OF   LABOR  IN   VERTEX  PRESENTATION. 

In  cephalic  presentations,  when  the  head  is  well  flexed  and  the  occipi- 
tal and  parietal  bones  about  the  posterior  fontanelle  constitute  the 
presenting  part,  it  is  called  a  vertex  presentation. 

This  is  the  most  frequent  of  all  presentations;  in  20,000  consecutive 
labors  at  the  Sloane  Hospital,  occurring  in  94.4  per  cent,  of  the  cases. 

The  vertex  presentation,  moreover,  is  the  most  favorable  and  if  with 
a  vertex  presentation  the  occiput  lies  anteriorly,  we  have  the  ideal  posi- 
tion for  the  fetus  at  the  beginning  of  labor.  The  mechanism  of  labor  in 
vertex  presentations  may  be  taken  as  the  type  of  mechanism  in  all 
presentations  and  a  thorough  understanding  of  this  will  make  the  com- 
prehension of  the  whole  subject  of  mechanism  of  labor  comparatively 
easy. 

1  The  position  of  the  Fetus.  Researches  in  Obstetrics,  Edinburgh,  1868,  pp.  14-37;  also 
EdiL  burgh  Med.  and  S\u-g.  Journal,  1855. 

2  Die  Lagenverhaltnisse  bei  Fnih-und  Zwillingsgeburten,  Scanzoni's  Beitrage,  1860, 
iv.  279-292. 

sUeber  den  Schwerpunkt  der  Frucht,  Zentralbl.  f.  Gyn.,  1900,  No.  40,  1033-36;     Die 
Ursachen  der  Kindeslagen,  Archiv  f.  Gyn.,  1904,  Ixxi,  541-651. 
4  Obstetrics,  1908,  p.  210. 


252  THE  MECHANISM    OF  LABOR 

The  following  tables^  each  from  a  large  series  of  eases,  show  the  relative 
frequency  of  the  different  positions  in  vertex  presentation: 

Dubois,'  Williams,'-  Cragin, 

from  1913  cases.  from  1687  cases  from  2000  cases. 

L.  O.  A.  71.00  per  cent.  60.9  per  cent.  63.25  per  cent. 

R.  O.  P.  25.00  per  cent.  14.2  per  cent.  8. 10  per  cent. 

R.  O.  A.    2.87  per  cent.  22.3  per  cent.  25.70  per  cent. 

L.  O.  P.     0.63  per  cent.  2.6  per  cent.  2.95  per  cent. 

The  variation  in  the  relative  frequenc,^'  of  the  positions  R.  O.  A.  and 
R.  O.  P.  in  the  different  series  undoubtedh'  results  from  the  fact  that 
a  large  percentage  of  cases,  which  at  the  beginning  of  labor  are  R.  O.  P., 
become  R.  O.  A.  as  labor  advances.  Examinations  made  late  in  labor 
would  give  a  predominance  of  R.  O.  A.  positions,  while  only  tho.se  made 
early  would  give  the  true  result.  This  reasoning  holds  true  with  regard 
to  the  L.  O.  P.  and  L.  O.  A.  positions  also,  but  is  of  less  importance, 
because  of  the  relative  infrequency  of  the  L.  O.  P.  positions. 

Several  reasons  have  been  given  for  the  preference  of  the  fetal  head 
for  the  right  oblique  rather  than  the  left  oblique  diameter  of  the  pelvis. 
The  rectum  is  on  the  left  side  and  this  makes  the  left  oblique  diameter 
practically  the  smaller,  while  external  measurements  at  least  would 
indicate  that  the  left  oblique  is  actualh'  smaller,  usually  by  about  ^  cm. 
The  lateral  torsion  of  the  uterus  to  the  right  with  its  left  border  slightly 
anterior,  would  also  account  for  this  tendency. 

The  reason  for  the  predominance  of  the  L.  O.  A.  over  that  of  R.  O.  P. 
may  be  found  in  the  shape  of  the  fetal  ovoid.  This  presents,  as  will  be 
remembered,  a  conca\'ity  on  its  abdominal  side,  into  which  the  convexity 
of  the  mother's  vertebral  column  readily  fits,  thus  making  the  anterior 
position  of  the  fetal  back  the  easier. 

A  study  of  the  figures  (Figs.  157  and  15S)  will  show  why  the  fetal 
head  seeks  the  oblique  diameter  at  the  brim  of  the  pelvis  rather  than 
the  transverse  or  anteroposterior  diameter,  and  why  it  traverses  the 
pelvis  as  it  does. 

The  diameters  at  the  brim  of  the  pelvis  are:  11  cm.  anteroposteriorly, 
12  cm.  obliquely,  and  13  cm.  transversely.  The  transverse  diameter, 
however,  is  not  available,  for  the  promontory  of  the  sacrum  juts  forw^ard 
at  the  widest  part,  throwing  the  presenting  head  forward  where  the 
diameter  is  much  less. 

In  the  hollow  of  the  pelvis  all  three  of  the  diameters,  anteroposterior, 
oblique,  and  transverse  are  12  cm.  each.  At  the  outlet  tlie  transverse 
and  oblique  diameters  are  each  11  cm.  while  the  anteroposterior  is  only 
9.5  cm.  However,  when  the  tip  of  the  coccyx  is  pushed  back,  as  it  is 
during  labor,  this  last  diameter  becomes  11.5  cm.  It  is  seen,  therefore, 
that  the  longest  available  diameter  at  the  brim  is  one  of  the  obliques,  in 
the  hollow  of  the  pelvis  all  are  long,  while  at  the  outlet  the  anteroposterior 
is  the  longest. 

*  Quoted  by  Pinard,  also  by  Lusk.    The  science  and  art  of  midwifery,  1895,  p.  175. 
"  Obstetrics,  1908,  p.  254. 


MECHANISM  OF  ANTERIOR  POSITIONS  OF  THE  VERTEX    253 

The  diameters  of  the  fetal  head  are  the  biparietal,  9.25  cm.;  the  sub- 
occipitobregmatic,  9.5  cm.;  the  suboccipitof rental,  10.5  cm.;  the  occipito- 
frontal, 11.5  cm.;  while  the  occipitomental  is  13.25  cm. 

It  is  obvious  that  the  biparietal  diameter  will  meet  with  no  obstruc- 
tion in  any  direction  as  it  passes  through  the  normal  pelvis.  It  is  also 
apparent  from  the  other  measurements  that  the  more  sharply  flexed 
the  head  is  on  the  body,  the  smaller  will  be  the  diameter  presented. 

In  sharp  flexion  the  suboccipitobregmatic,  9.5  cm.,  would  present, 
followed  closely  by  the  suboccipitofrontal,  10.5  cm.  These  diameters 
could  pass  through  any  diameter  of  the  normal  pelvis.  With  the  head 
much  extended  the  largest  possible  diameter,  the  occipitomental,  13.25 
cm.,  would  be  presenting.  This  could  not  pass  through  any  of  the  pelvic 
diameters.  Some  flexion  is  therefore  absolutely  necessary.  (If  the  head 
is  very  sharply  extended  a  new  diameter,  the  frontomental,  presents — a 
face  presentation.  This  will  be  discussed  later.)  With  the  head  in 
moderate  flexion,  the  occipitofrontal  diameter,  11.5  cm.,  would  present. 
This  diameter  could  only  enter  the  brim  of  the  pelvis  in  one  of  the 
obliques;  in  midpelvis  it  would  be  free  in  any  direction,  and  at  the 
outlet  it  could  pass  only  in  the  anteroposterior  diameter.  If  the  occipito- 
frontal diameter  presented,  we  should  expect  it  therefore  to  enter  the 
pelvis  obliquely,  to  turn  in  midpelvis,  and  to  leave  the  pelvis  antero- 
posteriorly. 

Such,  as  a  matter  of  fact,  is  the  manner  in  which  the  fetal  head  does 
pass  through  the  normal  pelvis;  and  it  is  the  occipitofrontal  diameter 
which  presents  at  the  brim.  As  the  fetus  lies  in  the  uterus  before  labor 
with  head  downward  in  its  normal  attitude  of  universal  flexion,  the 
head  is  in  moderate  flexion.  There  is  no  reason  to  suppose  the  head  is 
in  sharp  flexion.  Indeed  abdominal  palpation  would  seem  to  indicate 
that  it  is  not,  and  in  the  absence  of  any  marked  pressure  there  is  nothing 
to  cause  it.  Sharp  flexion  does  not  occur  until  in  labor  the  head  is 
crowded  down  on  to  the  pelvic  floor,  or  against  some  other  obstruction. 

Therefore,  as  the  head  in  moderate  flexion  presents  at  the  pelvic  brim 
before  labor,  it  is  the  occipitofrontal  diameter  which  lies  across  the 
pelvis. 

This  diameter  (11.5  cm.)  cannot  settle  into  the  brim  in  the  antero- 
posterior or  transverse  diameters,  because  as  we  have  seen,  they  are  too 
small,  and  it  necessarily  selects  one  of  the  oblique  diameters.  The  reason 
for  the  more  frequent  selection  of  the  right  oblique  has  been  explained. 

Thus  at  the  onset  of  labor  the  head  is  most  frequently  found  in  the 
L,  O,  A.  position.  As  the  mechanisms  of  the  L.  O.  A,  and  the  R.  O,  A. 
positions  are  exactly  similar,  these  will  be  described  together. 

MECHANISM   OF   ANTERIOR   POSITIONS    OF    THE   VERTEX 
(L.  O.  A.  AND  R.  O.  A,). 

Diagnosis. — For  a  clear  understanding  of  the  mechanical  problem 
presented  an  accurate  diagnosis  of  the  presentation  and  position  is  neces- 
sary.   This  is  made,  as  already  indicated  on  page  177,  by  the  combination 


254 


THE  MECHANISM  OF  LABOR 


of  three  methods:     (A)  Abdominal  palpation.      (B)  Auscultation  of  the 
fetal  heart.    (C)   Vaginal  examination. 


I'iG.   187. — Palpation  of  fetal  back  and  small  parts 


Fig.  188. — Palpation  of  small  parts  in  the  L.  O.  A.  position. 


MECHAXISM   OF  ANTERIOR   POSITIONS   OF   THE   VERTEX     255 

A.  Abdominal  Palpation. — In  the  manner  just  referred  to,  the  obstet- 
rician, standing  with  face  toward  the  patient's  feet,  palpates  the  two  sides 
of  the  abdomen  and  locates: 


Fig.   189. — Palpation  of  small  ijart;  in  rh,.  I{.  (  ),  A.  position. 


Fig.   190. — Palpation  of  the  lower  fetal  pole. 

1.  Fetal  hack  and  small  parts  (see  Fig.  187). 

In  the  L.  O.  A.  position  the  fetal  back  is  on  the  left  and  the  small 
parts  are  on  the  right  of  the  mother's  abdomen  (see  Fig.  1S8). 


256 


THE  MECHANISM  OF  LABOR 


In  the  R.  O.  A.  position  the  location  of  the  fetal  back  and  small  parts 
is  just  reversed,  the  back  lying  to  the  right  and  the  small  parts  to  the 
left  (see  Fig.  189). 


I'll..    I'Jl.    -PaliiatiDii  of  the  upper  fetal  pole. 


Fig.  192. — Point  of  greatest  intensity  of  fetal  heart  sounds  in  the  L.  O.  A.  position. 


MECHANISM  OF  ANTERIOR  POSITIONS  OF   THE   VERTEX    257 

2.  Palpation  of  the  presenting  fetal  pole  determines  that  the  fetal  head 
has  below  and 'that  in  the  L.  O.  A.  position  the  least  prominent  part  of 
the  head  is  on  the  left  side,  the  side  of  the  fetal  back,  while  the  most 
prominent  part  of  the  head  is  on  the  right,  the  side  of  the  fetal  small 
parts  (see  Fig.  190).    In  the  R.  O.  A.  position  these  relations  are  reversed. 

3.  Palpation  of  the  upper  fetal  pole  discloses  the  characteristics  of  the 
breech  (see  Fig.- 191). 

B.  Auscultation  of  the  Fetal  Heart. — Auscultation  of  the  fetal  heart 
determines  the  fact  that  in  the  L.  O.  A.  position  the  point  of  greatest 
intensity  is  on  the  left,  approximately  at  the  centre  of  a  line  between 
the  umbilicus  and  the  anterior  superior  spine  of  the  ilium  (see  Fig.  192). 
In  the  R.  O.  A.  position  the  point  of  greatest  intensity  is  in  a  corre- 
sponding location  on  the  right  side  (see  Fig.  193). 


Fig.   193. — Point  of  greatest  intensity  of  fetal  heart  sounds  in  the  R.  O.  A.  position. 

C.  Vaginal  Examination. — When  the  cervix  is  sufficiently  dilated  to 
allow  the  finger  to  palpate  the  sutures  and  fontanelles,  it  is  found  that 
in  the  L.  O.  A.  position  the  sagittal  suture  lies  in  the  right  oblique 
diameter  of  the  pelvis,  with  the  small,  posterior  fontanelle  near  the  left 
iliopectineal  emiiience,  while  the  large  ^anterior  fontanelle  lies  in  the 
direction  of  the  right  sacro-iliac  joint.  The  examining  finger  first  impinges 
on  the  right  parietal  bone. 

In  the  R.  O.  A.  position  these  relations  are  reversed.  The  sagittal 
suture  lies  in  the  left  oblique  diameter  of  the  pelvis,  with  the  posterior 
fontanelle  near  the  right  iliopectineal  eminence  and  the  anterior  fon- 
tanelle in  the  direction  of  the  left  sacro-iliac  joint.  The  examining  finger 
first  impinges  on  the  left  paiietal  bone. 

Mechanism. — In  L.  O.  A.  and  R.  O.  A.  positions  of  the  vertex  the 
mechanism  consists  of  engagement,  molding,  flexion,  descent,  lateral 
17 


258  THE  MECHANISM  OF  LABOR 

inclination,  internal  rotation,  extension,  restitution  and  external  rotation, 
birth  of  the  shoulders  and  l)ody. 

Engagement. — The  head,  in  the  pelvic  brim,  is  usually  on  an  even 
keel,  so  to  speak,  with  the  parietal  bones  on  the  same  level  with  each 
other. 

If  the  woman  has  a  i)endulous  abdomen,  however,  and  the  uterus 
falls  f()r\\ard,  the  sagittal  suture  approaches  the  promontory  and  the 
anterior  parietal  bone  is  felt  first  through  the  cervix  (Naegele's  obli- 
quity). With  the  axis  of  the  uterus  backward  the  sagittal  suture 
approaches  the  symphysis;  and  the  posterior  parietal  bone  is  felt  first 
(\'arnier's  obliquity). 

The  method  of  engagement  has  given  rise  to  much  discussion,  many 
holding  that  Naegele's  obliquity  generally  exists,  and  others  favoring 
Varnier's  obliquity.  It  is  probable  that  under  normal  conditions  neither 
the  one  nor  the  other  exists,  the  biparietal  diameter  lying  directly  in 
the  plane  of  the  pelvic  brim.  The  extent  of  the  engagement  of  the  head 
depends  upon  the  size  of  the  j)elvis.  When  this  is  relati\ely  large  the 
head  may  sink  to  midpelvis  before  labor.  In  smaller  pelves  it  simply 
dips  lightly  into  the  brim.  In  deformed  pelves  there  is  often  no  engage- 
ment until  expulsive  pains  have  taken  place.  In  multigravida?,  owing 
to  the  lax  abdominal  walls  which  are  easily  distended  and  do  not  readily 
contract  to  push  the  uterus  down,  the  head  generally  engages  but  slightly 
until  after  labor  is  well  ad\'anced.  In  primigravidie  the  head  engages 
much  sooner  and  to  a  greater  extent  before  labor. 

With  the  beginning  of  labor  there  is  at  first  little  change  in  the  posi- 
tion of  the  fetus,  and  during  the  dilatation  of  the  cervix  the  head  moves 
little  if  any.  With  the  full  dilatation  of  the  cervix  and  the  advent  of 
expulsive  pains,  howe^^er,  the  head  begins  to  move.  Three  changes  take 
place  together,  molding,  flexion  and  descent. 

Molding. — By  molding  is  meant  the  compression  of  the  head  so  that 
its  shape  corresponds  more  closely  to  that  of  the  pelvic  canal. 

In  large  pelves  little  molding  is  necessary,  and  after  labor  in  such  cases 
there  is  slight  evidence  of  it.  In  smaller  pelves,  however,  molding  is 
necessary.  The  head  is  compressed  laterally,  so  that  the  transverse 
diameters  of  the  head  are  smaller,  while  the  longitudinal  diameters  are 
increased.  This  has  the  effect  of  making  the  head  longer  and  narrower. 
The  transverse  diameter  is  lessened  from  1.5  to  2  cm.  (Edgar).'  This 
is  accomplished  by  the  closing  of  the  sagittal  suture  and  the  overlapping 
of  the  parietal  bones.  The  anterior  parietal  bone  overlaps  the  posterior 
parietal  and  both  o\'erlap  the  occipital  and  frontal  bones.  In  L.  O.  A. 
positions  the  right  parietal  bone  overlaps  the  left,  and  bulges  slightly, 
while  the  posterior  or  left  is  flattened.  In  R.  O.  A.  positions  the  left 
overlaps  the  right  parietal  bone,  which  is  posterior  and  flattened.  At 
the  same  time  there  is  flattening  of  the  skull  at  the  brow  and  around 
the  anterior  fontanelle.  The  presenting  part  is  thus  molded  into  a 
long,  narrow  cone.    At  the  point  of  least  resistance,  that  is,  at  the  cervi- 

'  Practice  of  Obstetrics,  p.  503. 


MECHANISM  OF  AXTERIOR  POSITIOXS  OF   THE   VERTEX    259 

cal  canal,  there  appears  a  swelling  of  the  scalp  in  the  loose  connective 
tissue,  from  the  edema  and  obstructed  venous  circulation,  which  is 
kno'^Ti  as  the  "caput  succudaneum." 

In  the  L.  O.  A.  position  this  will  be  found  on  the  right  parietal  bone 
at  the  posterosuperior  angle.  In  the  R^O.  A.  ])osition  it  will  be  found 
on  the  left  parietal  bone  at  its  posterosuperior  angle.  Thus  after  labor 
the  original  position  can  often  be  told  by  the  molding  and  by  the  posi- 
tion of  the  caput  succudaneum. 

IMolding  favors  flexion  and  descent. 

Flexion. — A  moderate  amount  of  flexion  exists  before  labor,  which  is 
increased  during  labor.  The  cause  of  this  flexion  is  easily  understood 
when  the  manner  in  which  the  head  is  attached  to  the  vertebral  column 
is  seen  (see  Fig,  176).  The  articulation  is  nearer  the  occiput  than  the 
sinciput,  consequently  the  downward  pressure  exerted  by  the  uterus 
on  the  fetal  body  will  be  transmitted  more  directly  to  the  occiput 
and  will  tend  to  force  this  downward.  ]^Ioreover  the  head  in  its  articu- 
lation with  the  vertebral  column  is  like  a  two-armed  lever,  of  which  the 
occiput  constitutes  the  shorter  and  the  sinciput  the  longer  arm.  As  the 
head  meets  counter-pressure  from  below,  that  exerted  on  the  sinciput, 
the  longer  arm  acts  to  greater  advantage  than  that  exerted  on  the 
shorter  arm,  the  occiput,  and  the  sinciput  is  thus  pushed  up,  flexion 
resulting.  j. 

Full  flexion  usually  does  not  occur  until  the  head  is  on  the  pelvic 
floor,  for  usually  there  is  no  resistance  until  this  is  reached.  Resistance 
higher  up,  as  in  small  or  deformed  pelves  will  cause  flexion  sooner. 

Descent. — ^Molding  and  flexion  favor  descent  which  takes  place  with 
them.  This  is  caused  by  the  uterine  contractions,  acting  indirectly 
through  the  liquor  amnii,  or  by  direct  pressure  on  the  fetus;  by  the 
abdominal  contractions;  and  by  the  straightening  out  of  the  fetal 
body. 

Lateral  Inclination. — As  the  head  descends  in  the  pelvis,  the  posterior 
parietal  bone  (the  left  in  L,  O.  A.)  strikes  the  promontory  of  the  sacrum 
and  is  retarded,  the  head  thus  being  turned  sidewise.  This  serves  to 
bring  the  axis  of  the  head  perpendicular  to  the  brim  and  makes  engage- 
ment easier.  If  it  were  not  for  this  lateral  inclination  the  head  would 
impinge  on  the  sjTnphysis  pubis. 

As  the  posterior  pelvic  wall  from  the  promontory  of  the  sacrum  to 
the  tip  of  the  coccyx  is  12.5  cm.  long,  and  the  anterior  pelvic  wall  from 
the  symphysis  pubis  to  the  .under  surface  of  the  pubic  arch  is  only  4 
cm.  long,  it  is  plain  that  the  posterior  part  of  the  fetal  head  must  descend 
more  rapidly  than  the  anterior  if  both  parts  are  to  reach  the  outlet  at 
the  same  time.  To  this  movement  the  name  synclitism  has  been  given 
(see  Fig.  194). 

Dilatation  of  the  Cervix. — ^The  cervix  becomes  softer,  shorter,  and  its 
canal  more  dilated.  These  changes  are  due  to  increased  vascularity 
making  it  softer;  to  contraction  of  the  longitudinal  muscular  fibers, 
making  it  shorter;  and  to  the  relaxation  of  the  circular  fibers,  allowing 
dilatation.     The  dilatation  is  also  caused  by  intra-uterine  pressure  of 


260 


THE  MECHANISM  OF  LABOR 


the  bag  of  waters  acting  as  a  wedge,  and  after  rupture  of  the  bag  of  waters 
by  the  direct  pressure  of  the  presenting  part  itself  (in  vertex  presenta- 
tion, the  head). 


Fig    194. — Lateral  inclination  and  synclitism. 


Fio.   195. — Illustration  of  course  taken  hy  hall  on  roof. 


Internal  Rotation. — As  the  head  reaches  the  pelvic  floor  the  occiput 
rotates  forward  to  the  median  line  under  the  pubic  arch,  so  that  the 


MECHANISM  OF  ANTERIOR  POSITIONS  OF  THE  VERTEX     261 

head  lies  with  its  long  diameter  in  the  anteroposterior  diameter  of  the 
pelvis.  In  this  position  it  is  born.  Except  in  very  large  pelves,  or  with 
very  small  heads,  this  rotation  always  occurs  and  is  essential  for  delivery. 
The  cause  of  the  forward  rotation  of  the  occiput  has  given  rise  to  more 
discussion  than  has  any  other  part  of  the  mechanism  of  labor.  Medical 
literature  is  full  of  theories  and  explanations. 

For  many  years  it  was  thought  that  the  bony  inclined  planes  at  the 
side  of  the  pelvis,  as  already  described  on  page  224,  were  the  chief  factors 
in  internal  rotation  of  the  fetal  head,  but  while  they  might  be  used  to 
explain  the  rotation  of  the  anterior  position  of  the  occiput  (L.  O.  A.  or 
R.  O.  A.)  forward  to  an  O.  A.,  or  a  posterior  position  of  the  occiput  (R. 
O.  P.  or  L.  O.  P.)  backward  to  an  O.  P.,  they  could  not  explain  the  rota- 
tion of  a  posterior  position  of  the  occiput  forward  to  an  O.  A.,  as  these 
inclined  planes  are  fixed  quantities,  always  acting  in  the  same  manner 
in  the  same  pelvis.  It  is  now  considered  that  the  inclined  planes  of 
the  pelvis  or  pelvic  grooves  act  as  the  slopes  of  a  two-slope  roof  act  on 
a  ball,  one  turning  the  ball  one  way  to  the  gutter,  the  other  another  way 
to  the  gutter  (see  Fig.  195).  The  pelvic  grooves  simply  guide  to  the 
pelvic  floor  anteriorly  or  posteriorly  that  which  rests  upon  them. 

It  is  probable  that  no  one  cause  is  entirely  responsible  for  internal 
rotation  of  the  fetal  head,  but  the  chief  cause  is  the  levatores  ani  muscles 
of  the  pelvic  floor.  Contraction  of  these  muscles  tends  to  throw  forward 
any  body  resting  on  them.  With  the  head  well  flexed  the  occiput  is  its 
lower  part  and  first  strikes  the  pelvic  floor  and  is  then  turned  forward 
under  the  pubic  arch. 

That  the  internal  rotation  of  the  fetal  head  is  chiefly  caused  by  the 
pelvic  floor  has  received  its  most  convincing  proof  from  the  experiments 
of  Paul  Dubois.  He  tried  placing  fetal  cadavers  of  various  sizes  in  the 
uterus  of  a  w^oman  who  had  just  died  in  parturition.  They  were  placed 
in  the  uterus  with  occiput  posterior  and  were  then  pushed  from  above 
downw-ard  through  the  parturient  canal.  For  two  or  three  times  (each 
successive  fetus  being  larger  than  the  preceding)  the  fetal  head  rotated 
so  that  the  occiput  was  born  in  the  anterior  position.  After  the  second 
or  third  trial  the  pelvic  floor  became  so  stretched  that  this  rotation  did 
not  occur  and  the  head  was  born  with  occiput  in  the  posterior  position. 

This  experimental  result  was  verified  by  Edgar^  who  screwed  a  swivel 
into  the  head  of  a  fetal  cadaver  and  repeatedly  dragged  the  head  through 
the  pelvis  of  a  woman  w^ho  had  just  died  in  parturition.  He  found  that 
the  head  invariably  rotated  to  the  front,  even  w^hen  it  entered  the  pelvis 
with  the  occiput  in  posterior  positions,  so  long  as  the  pelvic  floor  retained 
its  integrity;  but  when  the  tonicity  of  the  floor  became  impaired  by 
overstretching,  the  head  traversed  the  pelvis  in  very  nearly  the  same 
position  as  that  in  which  it  had  entered-. 

Rotation  of  the  occiput  is  easy  when  the  head  is  well  flexed,  for  then 
the  presenting  part  is  shaped  like  a  ball,  the  suboccipitobregmatic  diam- 
eter measuring  9.5  cm.  and  the  biparietal  diameter  9.25  cm.     When 

1  Practice  of  Obstetrics,  1907,  p.  442. 


262  THE  MECHANISM  OF  LABOR 

the  occiput  strikes  one  side  of  the  gutter-sliaped  pelvic  floor  obliquely,  it 
naturally  slides  off  anteriorly  as  would  a  ball  on  striking  the  gutter 
of  a  house  obliquely. 

Again  the  anteroposterior  diameter  of  the  pelvis  is  the  largest  diam- 
eter at  the  outlet,  and  the  long  diameter  of  the  head  naturally  seeks 
this  when  the  head  is  forced  down  by  the  intermittent  contractions  of 
the  uterine  and  abdominal  muscles. 

Extension. — After  the  head  has  been  molded  sufficiently,  has  been 
well  flexed,  has  reached  the  pelvic  floor  and  has  rotated  so  that  the 
occiput  has  turned  forward  to  the  pubic  arch,  the  occiput  continues 
to  advance  until  it  has  passed  under  the  arch  for  about  3  cm.  There  the 
advance  of  the  occiput  ceases  temporarily,  flexion  ends,  and  extension 
begins  by  the  advance  of  the  sinciput,  which  is  pushed  out  little  by  little, 
advancing  and  receding  with  the  intermittent  pains,  upward  and  for- 
ward o\er  the  perineiun,  until  successively  the  forehead,  eyes,  nose, 
mouth  and  chin  are  born.  The  nape  of  the  neck  is  firmly  crowded  against 
the  pubic  arch  and  the  occi])ut  approaches  this  little  by  little,  as  the  head 
is  extended  and  the  forehead  rises  higher  and  higher  over  the  perineum. 
Thus  the  head  is  born  by  extension.  The  reason  for  this  extension  is 
easily  understood.  The  anterior  pelvic  wall  is  4  cm.  deep,  and  the 
fetal  neck,  from  shoulders  to  occiput,  is  7  cm.  long.  Consequently  when  the 
occiput  has  i)assed  under  the  pubic  arch  for  a  distance  of  3  cm.  it  can  go 
no  further  until  the  shoulders  descend,  and  this  cannot  happen  until 
the  head  is  entirely  born,  for  the  pelvis  is  not  large  enough  to  hold  both 
the  head  and  body  at  the  same  time.  The  occiput  being  stationary,  the 
expulsive  forces  acting  on  the  fetal  body  will  be  effective  on  the  sinciput 
alone.  There  is  nothing  to  ])revent  the  a(hance  of  this,  and  it  is  there- 
fore pushed  on  up  over  the  perineum — extension.  As  the  head  extends, 
the  forehead  naturally  slides  upward,  for  this  is  the  direction  of  the 
pelvic  outlet,  and  it  is  the  only  direction  in  which  it  can  go.  The  uterus 
pressing  downward  and  the  perineum  pressing  upward,  give  a  resultant 
force  in  the  direction  of  the  outlet.  When  the  perineum  is  \ery  lax  or 
tears,  extension  is,  of  course,  not  so  complete.  Conversely,  the  way  to 
prevent  tearing  of  the  perineum  is  to  favor  complete  extension  of  the 
head,  by  which  the  forehead  is  lifted  over  and  away  from  the  perineum. 
It  is  to  be  noted,  howe\'er,  that  extension  does  not  take  place  until  the 
occiput  has  passed  well  under  the  pubic  arch.  This  gi\'es  the  smallest 
diameter  for  passage  through  the  vaginal  outlet,  the  suboccipitobreg- 
matic  followed  by  the  suboccipitofrontal,  9.5  cm.  and  10.5  cm.  respec- 
tively. If,  through  the  action  of  the  accoucheur,  extension  should  be 
made  to  take  place  before  the  occiput  has  passed  the  pubic  arch,  the 
occipitofrontal  diameter,  11.5  cm.,  would  have  to  pass  through  the  outlet, 
with  greater  difficulty  and  with  more  certain  damage  to  the  perineum. 

Restitution  and  External  Rotation. — As  the  chin  slips  over  the  perineum, 
the  head  is  fully  born.  This  immediately  drops  down  so  that  the  chin 
approaches  the  anus  of  the  mother.  At  the  same  time  the  occiput  may 
be  seen  to  turn  slightly  to  that  side  to  which  it  previously  pointed. 
The  neck,  as  it  were,  "  untwists"  itself.   The.occiput  having  rotatefl  toward 


MECHANISM  OF  ANTERIOR  POSITIONS  OF   THE   VERTEX    263 

the  median  line  without  corresponding  movement  of  the  shoulders, 
naturally  turns  part  way  back  again,  as  soon  as  the  head  is  free.  This 
is  called  "restitution"  of  the  head.  There  is  usually  a  slight  cessation 
of  pains  and  then  the  occiput  is  observed  to  turn  decidedly  to  the  side 
toward  which  it  originally  pointed.  This  seems  like  a  continuation 
of  the  original  movement  of  restitution,  but  is  much  more  marked  and 
has  a  different  cause.  This  is  "external  rotation"  and  is  caused  by  the 
rotation  of  the  shoulders,  as  they  enter  the  brim  of  the  pelvis.  In  an 
L.  O.  A.  position,  the  external  rotation  of  the  occiput  is  toward  the 
mother's  left  thigh.     In  an  R.  O.  A.  position,  it  is  toward  her  right  thigh. 

The  long  diameter  of  the  shoulders  is  at  right  angles  to  the  long  diam- 
eter of  the  head.  Consequently  it  will  occupy  the  opposite  diameter 
from  that  of  the  head.  In  an  L.  O.  A.  position,  the  head  is  in  the  right 
oblique  diameter,  while  the  shoulders  will  enter  the  left  oblique.  The 
right  shoulder  will  be  anterior,  and  from  the  obliquity  of  the  pelvic  canal 
will  first  strike  the  pelvic  floor  and  will  be  rotated  forward  to  the  pubic 
arch,  the  posterior  or  left  shoulder  being  necessarily  rotated  posteriorly  to 
the  sacrum.  This  turning  of  the  shoulders  from  right  to  left,  causes  the 
turning  of  the  occiput  from  right  to  left — external  rotation. 

In  an  R.  O.  A.  position  the  shoulders  occupy  the  right  oblique  diameter, 
and  turn  to  the  right  as  the  left  shoulder  rotates  anteriorly,  thus  causing 
the  occiput  to  rotate  to  the  right  externally. 

Very  rarely  external  rotation  takes  place  in  the  opposite  direction 
from  which  the  occiput  originally  pointed.  This  only  happens  where 
the  pelvis  is  very  large  or  the  fetus  very  small,  and  is  caused  by  the 
fact  that  the  shoulders,  being  relatively  small,  can  enter  the  pelvis  in  any 
direction  irrespective  of  the  obliques,  that  is,  transversely.  Consequently 
either  shoulder  has  an  equal  chance  of  rotating  anteriorly.  With  a  very 
small  premature  fetus  the  shoulders  sometimes  do  not  rotate  at  all 
but  are  born  transversely.  This  cannot  happen  at  term  with  normal 
relations  between  child  and  pelvis,  for  the  bisacromial  diameter  of  the 
fetus  in  12.25  cm.,  while  the  transverse  diameter  at  the  outlet  of  the  pelvis 
is  only  11  cm. 

Birth  of  the  Shoulders. — The  shoulders  enter  the  brim  of  the  pelvis  in 
one  of  the  oblique  diameters.  This  they  can  readily  do  as  they  are  easily 
compressed,  and  the  bisacromial  diameter  is  12.25  cm.  and  that  of  the 
oblique  is  12  cm.  They  then  rotate,  the  anterior  to  the  pubic  arch,  and 
the  posterior  to  the  sacrum,  as  we  have  seen.  They  now  occupy  the 
anteroposterior,  or  widest  diameter  of  the  outlet,  as  did  the  head. 
Birth  of  the  shoulders  can  now  take  place  in  one  of  three  ways:  the 
posterior  first,  followed  by  the  anterior;  the  anterior  first,  followed  by 
the  posterior;  or  both  together.  It  is  clear  that  either  the  first  or  second 
ways  are  favorable,  while  the  last  is  distinctly  unfavorable,  and  can  only 
take  place  with  a  small  fetus  or  with  much  compression  of  the  shoulders 
(12.25  cm.,  bisacromial  diameter  of  the  fetus,  through  11.5  cm.,  antero- 
posterior diameter  at  the  pelvic  outlet).  However,  this  does  occur  at 
times,  though  rarely,  and  is  necessarily  dangerous  to  the  integrity  of  the 
soft  parts. 


264  THE  MECHANISM  OF  LABOR 

Frequently  tlie  method  is  that  of  the  posterior  shoulder  first.  Tlie 
anterior  shoulder  is  crowded  up  behind  the  pul)ic  arch  and  is  fixed 
there,  while  the  posterior  shoulder  is  pushed  out  and  up  over  the  peri- 
neum, as  was  the  oceii)ut  j)reviously.  After  this  is  born,  it  dr()])s  back 
over  the  i)erineum,  and  thus  releases  the  anterior  shoulder,  which  is 
rapidly  pushed  out  under  the  pubic  arch.  AVhen  this  mechanism  is  per- 
fect, the  diameter  passing  through  the  outlet  is  very  small,  from  the 
neck  to  the  opposite  shoulder  about  8  cm.,  and  deliv^ery  is  very  easy. 
This  method  is  more  likely  to  occur  if  the  head  is  supported  by  the  hand 
of  the  accoucheur,  as  is  often  the  case.  This  serves  to  raise  the  posterior 
shoulder,  or  at  least  to  prevent  its  falling  backward  in  the  vagina  and 
also  to  elevate  the  anterior  shoulder  behind  the  pubic  arch. 

^Yhen  the  woman  is  lying  on  her  back  unassisted,  the  second  method 
is  more  likely  to  occur.  Here  the  weight  of  the  unsupported  head  tends 
to  drag  down  the  anterior  shoulder,  so  that  it  comes  first  under  the 
pubic  arch,  the  posterior  shoulder  remaining  in  the  vagina,  and  then 
being  born  later  over  the  perineum,  as  the  forehead  follows  the  birth  of 
the  occiput. 

The  natural  method  of  delivery  among  savages  is  in  the  squatting 
position.  Here  the  recently  born  head  is  unsupported,  and  the  anterior 
shoulder  is  probably  born  first.  Leonet^  asserts  that  the  anterior  shoulder 
is  born  first  in  90  per  cent,  of  the  cases,  when  the  head  is  not  supported. 
When  it  is  supported,  the  ]:)Osterior  shoulder  is  born  first  in  90  per  cent, 
of  the  cases.  Edgar-  says  that  the  posterior  shoulder  is  born  first  two 
and  one-half  to  three  times  as  often  as  the  anterior,  but  in  nearly  all  his 
cases  upon  which  his  observations  were  based,  the  head  was  supported. 
At  the  Sloane  Hospital  the  anterior  shoulder  is  always  born  first,  as  the 
posterior  shoulder  is  held  Ijack  in  the  vagina  with  the  right  hand  of  the 
obstetrician,  while  the  head  is  forced  gently  downward  toward  the 
mother's  perineum  with  the  left  hand,  thus  causing  the  birth  of  the 
anterior  shoulder  first. 

The  reason  for  the  adoption  of  this  method  lies  in  the  fact  that  a  very 
small  laceration  of  the  perineum  at  the  fourchette  made  by  the  birth 
of  the  head  is  often  greatly  increased  when  the  posterior  shoulder  passes 
the  \-ulvar  outlet  and  may  be  still  further  increased  if  this  outlet  is  sub- 
jected to  tension  by  the  weight  of  the  trunk  in  the  disengagement  and 
delivery  of  the  anterior  shoulder  from  beneath  the  symphysis. 

It  has  seemed  to  the  author  that  there  was  less  tendency  to  laceration 
of  the  perineum  if  the  birth  of  the  head  was  followed  by  the  delivery 
of  the  anterior  shoulder  (see  Fig.  230),  during  which  only  the  trachelo- 
acromial  diameter  was  thrown  across  the  vulvar  outlet  and  then  by 
support  of  the  head  and  neck  the  posterior  shoulder  was  lifted  in  its 
delivery  away  from  any  little  tear  which  may  have  been  started  by  the 
head. 

Patients  at  the  Sloane  Hospital  are  all  delivered  in  the  dorsal  position. 

»  Quoted  from  Edgar,  Practice  of  Obstetrics,  1912  edition,  p.  428. 
*  Op.  cit. 


MEC-HANISM  OF  AXTERIOR  POSITIONS  OF  THE   VERTEX     265 

Birth  of  Body  and  Hips. — The  body  is  born  by  lateral  flexion  up  over 
the  perineum,  following  the  curve  of  the  vaginal  outlet.  The  obstetrician 
usually  lifts  the  body  of  the  child  as  it  is  born,  thus  aiding  nature.  The 
savage  woman,  anxious  to  claim  her  newborn,  might  well  be  supposed 
to  seize  it  and  lift  it  upward,  thus  unconsciously  following  the  method 
of  the  obstetrician  of  today  (King).  The  birth  of  the  body  is  very 
rapid,  however,  and  the  obstetrician  must  be  on  the  alert  or  it  will  be 
fully  born  before  it  can  be  lifted.  Anyone  watching  the  first  delivery 
by  a  student  will  appreciate  this.  The  hips  are  usually  so  small  that 
they  are  born  without  any  particular  mechanism.  However,  if  large  or 
the  pelvis  small,  the  mechanism  will  be  similar  to  that  of  the  shoulders, 
the  anterior  rotating  to  the  pubic  arch,  and  the  posterior  to  the  sacrum. 

The  arms  are  usually  born  flexed  on  the  chest,  practically  unchanged 
in  position,  during  labor.  At  times,  however,  they  are  found  in  abnor- 
mal attitudes,  as  prolapsed,  or  on  the  opposite  shoulder,  or  straight  out 
along  the  side.    This  is  usually  of  no  special  significance. 

The  legs  are  usually  born  still  flexed,  though  occasionally  they  may 
present  deviations  from  the  normal  attitude. 

Summary  of  Mechanism. — L.  O.  A.  Position. — The  occipitofrontal 
diameter  of  the  head  occupies  the  right  oblique  diameter  of  the  pelvis. 
Molding,  flexion  and  descent  occur  together,  chiefly  during  the  second 
stage.  When  the  occiput  strikes  the  pelvic  floor,  it  is  rotated  forward 
and  inward  to  the  pubic  arch — from  L.  O.  A.  to  O.  A.  It  passes  well 
under  the  pubic  arch  and  then  stops.  The  nape  of  the  neck  is  crowded 
up  against  the  pubic  arch  and  extension  begins  by  the  advance  of  the 
sinciput  which  slides  up  little  by  little  over  the  perineum,  while  fore- 
head, eyes,  nose,  mouth  and  chin  successively  emerge  over  the  perineum. 
The  head  is  now  completely  born  and  the  chin  drops  back  toward  the 
anus,  the  occiput  turning  slightly  to  the  mother's  left  thigh,  as  the  neck 
"  untwists" — restitution. 

Shortly  after  the  occiput  turns  decidedly  to  the  left — "external  rota- 
tion"— as  the  shoulders  engage  and  rotate.  These  enter  the  brim  in  the 
left  oblique  diameter,  the  right  anterior  or  lower  shoulder  rotates  to  the 
pubicarch.  This  slips  under  the  pubic  arch  for  a  short  distance  and  stops, 
while  the  posterior  is  forced  upward  over  the  perineum ;  or  the  anterior 
shoulder  is  crowded  up  against  the  pubic  arch,  while  the  posterior  first 
glides  over  the  perineum  followed  by  the  anterior.  The  body  is  born 
quickly  by  lateral  flexion  to  the  right,  the  hips  slipping  out  with  little 
or  no  mechanism.  After  labor  the  rigJit  parietal  bone  will  be  found  over- 
lapping the  left  parietal  bone  and  the  caput  will  be  found  over  right 
parietal  bone  at  its  posterosuperior  angle. 

R.  O.  A.  Position. — The  occipitofrontal  diameter  of  the  head  occupies 
the  left  oblique  diameter  of  the  pelvis.  Molding,  flexion,  and  descent 
occur  as  before,  the  occiput  rotates  forward  to  the  pubic  arch  but  from 
right  to  left— R.  O.  A.  to  O.  A. 

The  head  is  born  by  extension,  the  occiput  turning  to  the  mother's 
right  thigh  in  restitution  and  external  rotation.  The  shoulders  enter 
the  brim  in  the  right  obHque  diameter;    the  left,  anterior  and  lower 


266  THE  MECHANISM  OF  LABOR 

rotates  to  the  pubic  arch.  Delivery  follows  with  either  the  anterior  or 
posterior  shoulder  first,  and  the  body  is  born  by  lateral  flexion  to  the 
left.  The  Icjt  ])arietal  bone  will  be  found  overlai)i)ing  the  rlf/lit  parietal 
bone,  and  caput  will  be  found  on  the  left  i)arietal  bone  at  its  postero- 
superior  an^le. 


MECHANISM    OF    POSTERIOR   POSITIONS    OF    THE   VERTEX 
(R.  O.  P.  AND   L.  O.  P.). 

Frequency. — The  occiput  is  posterior  at  the  beginning  of  labor  in 
about  1 7  per  cent,  of  cases.  At  the  Johns  Hopkins  Hospital,  in  1687  cases, 
it  occurred  in  16.8  per  cent.  In  the  500  cases  of  Pinard  it  occurred  in 
49.8  per  cent,  or  in  nearly  one-half  of  the  cases,  while  in  the  1913  cases 
studied  by  Dubois  the  posterior  position  was  found  in  26.23  per  cent,  or 
a  little  over  one-fourth  of  the  series. 

In  the  Sloane  Hospital,  in  2000  cases  observed  during  the  first  stage  of 
labor,  posterior  position  occurred  in  11.0.5  per  cent. 

The  R.  O.  P.  position  is  much  more  frequent  than  the  L.  O.  P.  posi- 
tion. In  Dubois's  series  it  was  twenty-five  times  as  frequent.  In  Pinard's, 
approximately  three  and  one-half  times  as  frequent,  while  in  the  series 
of  Williams  it  was  about  five  times  as  frequent.  At  the  Sloane  Hospital 
it  was  about  three  times  as  frequent.  Therefore,  while  the  R.  O.  P. 
position  is  often  found,  the  L.  O.  P.  position  must  be  considered  as 
exceptional  and  rare. 

The  reason  for  this  preference  for  the  right  oblique  diameter  has 
already  been  discussed  (see  page  252). 

Etiology. — Inquiry  into  the  cause  of  posterior  positions  of  the  occiput 
at  the  beginning  of  labor  is  of  little  interest,  as  the  frequency  is  so  vari- 
able. In  Pinard's  cases  the  posterior  positions  occurred  practically  as 
often  as  the  anterior.  Lack  of  the  cause  or  causes  usually  operating 
to  bring  about  the  anterior  position  is  probably  the  reason.  The  con- 
cavity of  the  abdominal  side  of  the  fetal  ovoid,  corresponding  to  the 
convexity  of  the  mother's  vertebral  column,  tends,  it  is  supposed,  to 
cause  the  anterior  position.  In  other  words,  the  fetus  best  fits  the  pelvis 
in  the  anterior  position  of  the  occiput.  Slight  changes  in  the  shape  of 
the  fetal  ovoid  or  of  the  pelvis  may  make  the  posterior  position  the 
more  natural. 

Diagnosis. — By  employment  of  the  usual  methods  of  diagnosis: 
abdominal  palpation,  auscultation  of  the  fetal  heart,  and  vaginal 
examination,  it  is  determined  first  of  all  that,  in  the  posterior  positions 
of  the  vertex  there  is  an  absence,  on  both  sides  of  the  abdomen  in  front, 
of  the  feel  of  the  smooth,  firm  fetal  back,  felt  on  palpation  in  the  anterior 
positions  of  the  vertex;  and  that  on  auscultation  the  usual  point  of 
greatest  intensity  of  the  fetal  heart  sounds  is  not  near  the  centre  of  the 
line  joining  umbilicus  and  the  anterior  superior  iliac  spine  on  either 
side  (exceptionally  the  anterior  wall  of  the  fetal  chest  may  be  crowded 
up  against  the  anterior  wall  of  the  mother's  abdomen  so  as  to  make  the 


MECHANISM  OF  POSTERIOR  POSITIONS  OF   THE   VERTEX     267 

above  point  that  of  greatest  intensity  even  in  posterior  positions).  The 
first  diagnostic  features  are  therefore  negative,  although  of  great  value. 

Abdominal  Palpation. — Abdominal  palpation  does  detect  small  parts  of 
the  fetus  in  front,  and  palpatioiTof  the  lower  fetal  pole  in  the  R.  O.  P. 
position  detects  the  head  in  the  right  oblique  diameter  of  the  pelvis. 
-B^'this  time  a  posterior  position  is  usually  suggested,  and  recurrence  to 
the  abdominal  palpation  usually  detects  the  fact  that  the  small  parts 
are  on  the  left  side,  and  the  fetal  back  lies  in  the  right  flank. 

Auscultation  of  the  Fetal  Heart. — Palpation  of  the  upper  fetal  pole 
discloses  the  breech,  and  the  auscultation  of  the  fetal  heart  usually  shows 
its  point  of  greatest  intensity  in  the  right  flank,  outside  of  the  line  join- 
ing umbilicus  and  anterosuperior  iliac  spine  (see  Fig.  196). 


Fig.  196. — Point  of  greatest  intensity  of  fetal  heart  sounds  in  the  R.  O.  P.  position. 


Vaginal  Examination. — A'aginal  examination  shows  the  sagittal  suture 
in  the  right  oblique  diameter  of  the  pelvis  with  the  anterior  fontanelle 
near  the  left  iliopectineal  eminence,  and  the  posterior  fontanelle  in  the 
direction  of  the  right  sacro-iliac  joint.  The  examining  finger  usually 
first  impinges  on  the  left  parietal  bone. 

In  the  L.  O.  P.  position  these  relations  are  reversed.  The  fetal  back 
lies  in  the  left  flank,  the  small  parts  on  the  right  side  of  the  abdomen, 
and  the  head  in  the  left  oblique  diameter  of  the  pelvis  with  the  fore- 
head in  front.  Auscultation  usually  discloses  the  point  of  greatest 
intensity  of  the  fetal  heart  sounds  in  the  left  flank  (see  Fig.  197)  and 
vaginal  examination  shows  the  sagittal  suture  in  the  left  oblique  diameter 
with  the  anterior  fontanelle  near  the  right  iliopectineal  eminence,  and 
the  posterior  fontanelle  in  the  direction  of  the  left  sacro-iliac  joint.  The 
examining  finger  usually  first  impinges  on  the  right  parietal  bone. 


268  THE  MECHANISM  OF  LABOR 

Mechanism. — In  the  majority  of  cases  the  mechanism  of  the  posterior 
l)osition  (litters  but  shglitly  from  that  of  the  anterior.  The  occiput  rotates 
anteriorly  as  in  the  latter,  but  turns  through  1.35°  instead  of  45°,  while 
the  labor  as  a  consequence  is  somewhat  more  prolonged.  Varnier,^ 
from  a  study  of  labor  in  a  series  of  400  posterior  positions  and  6C0  ante- 
rior, found  that  in  posterior  positions  it  took  on  an  average  three  hours 
and  sixteen  minutes  longer  in  primigravida^  and  one  hour  and  fifty  min- 
utes longer  in  multigravidje  than  in  anterior  positions. 

In  over  90  per  cent,  of  the  cases  with  occiput  posterior,  anterior  rota- 
tion occurs.  In  the  author's  experience,  however,  this  percentage  applies 
to  hospital  practice  rather  than  to  private  practice  in  the  so-called 


■1 

Fig.   197. — Point  m  greatest  uitcnsity  of  fetal  heart  sounds  in  the  L.  O.  P.  position, 

"higher  walks  of  life."  Here,  with  lower  muscle  tone  and  higher  tension 
of  nervous  system,  spontaneous  anterior  rotation  occurs  much  less 
frequently. 

Molding,  descent  and  flexion  occur  as  in  the  -original  anterior  posi- 
tions. The  head  being  flexed,  the  occiput  first  strikes  the  pelvic  floor  and 
is  thrown  forward  by  the  resistance  of  the  pelvic  floor;  the  head  rotating 
from  R.  O.  P.  to  R.  O.  A.  or  from  L.  O.  P.  to  L.  O.  A.  when  labor  becomes 
the  same  as  in  the  original  anterior  positions. 

In  a  small  number  of  cases,  however,  rotation  of  the  occiput  takes 
place  in  the  opposite  direction,  or  posteriorly  to  the  hollow  of  the  sacrum. 

1  De  I'attitude  de  la  t^te  au  detroit  superieur  et  du  mechanisme  de  son  engagement, 
Annales  d'obstet.  et  de  Gyn.,  1897,  xh-iii,  422-444. 


MECHANISM  OF  POSTERIOR  POSITIONS  OF   THE   VERTEX     269 

Varnier^  gives  this  as  2  per  cent.,  Naegele^  as  1.37  per  cent.,  West^  as 
3  per  cent.,  Edgar^  as  4.04  per  cent.  At  the  Sloane  Hospital,  in  20,000 
deliveries,  it  occurred  337  times  or  1.6  per  cent.  (1  to  60)  = 

After  the  occiput  has  rotated  into  the  hollow  of  the  sacrum,  labor 
unassisted  may  end  in  one  of  three  ways. 

1,  The  head  is  forced  down  until  the  sinciput  strikes  the  pubic  arch. 
The  anterior  fontanelle  is  crowded  up  against  this  (see  Fig.  198)  and  the 
occiput  by  tardy  flexion  of  the  head  is  pushed  up  over  the  perineum; 
when  by  extension  the  brow,  nose  and  mouth  slip  down  under  the  pubic 
arch,  and  the  head  is  born  by  extension.  This  termination  takes  place 
only  when  the  fetus  is  small  or  the  pelvis  large.    The  labor  is  hard  and 


Fig.  198. — Mechanism  in  persistent  occipitoposterior  position. 

long,  the  head  is  greatly  molded,  and  the  perineum  is  terribly  stretched, 
and  unless  very  lax,  badly  torn.  The  reason  for  this  stretching  or  tear- 
ing is.F*^in.  In  the  anterior  position  the  nape  of  the  neck  catches  under 
the  pubic  arch,  the  occiput  being  already  born  before  the  head  comes 
over  the  perineum  (see  Fig.  199  and  200).  Consequently  it  is  the  sub- 
occipitofrontal  diameter  (10.5  cm.)  which  comes  through  the  vaginal 
outlet.  In  the  method  just  described  (see  Fig.  198)  it  looks  at  first  sight 
as  though  again  the  suboccipitofrontal  might  come  through  the  outlet. 
In  Fig.  198  it  is  the  suboccipitobregmatic  which  is  presenting  in  the 
bony  outlet,  but  the  neck  has  now  been  stretched  to  its  utmost,  and  the 


1  Op.  cit. 

2  Die  lehre  vom  Mechanismus  der  Geburt,  Mainz,  1838. 

3  Cranial  Presentation,  etc.,  Glasgow,  1857. 
■*  Practice  of  Obstetrics,  1905,  p.  597. 


270 


THE  MECHANISM  OF  LABOR 


Fig.  199. — Mechanism  in  occipito-anlerior  position 


Fig    200. — Mechanism  in  occipito-anterior  position,  later  stage. 


( 


MECHANISM  OF  POSTERIOR  POSITIONS  OF  THE   VERTEX    271 

occiput  can  rise  no  higher  over  the  perineum.  Consequently  the  sinci- 
put must  now  advance  and  extension  (late)  begins.  Extension  brings 
the  forehead  under  the  pubic  arch,  and  great  pressure  is  made  on  the 
perineum,  as  the  occipitofrontal  diameter  11.5  cm.  presents  at  the 
outlet.  At  this  point  the  perineum  usually  gives  way  unless  very  lax. 
Dubois  first  pointed  out  the  scientific  reason  for  the  difficulty  of  deliv- 
ery in  these  posterior  positions.  The  anterior  pelvic  wall  is  4  cm.  long, 
while  the  fetal  neck  is  7  cm.  long  from  shoulders  to  occiput.  Hence 
in  anterior  positions  the  occiput  easily  passes  under  the  pubic  arch  and 
rises  above  it  before  the  shoulders  are  born,  as  we  have  seen  fFig._200). 
The  posterior  pelvic  wall,  however,  from  the  promontory  of  the  sacrum 


Fig.  201. — Tracing  of  child's  head 
immediately  after  birth.  Persistent 
occiput  posterior. 


Fig.  202. — Same  head  as  shown  in  Fig. 
201.    One  week  later. 


to  the  tip  of  the  coccyx  is  12.5  cm.  and  12.5  cm.  from  this  to  the  edge 
of  the  perineum,  25  cm.  in  all.  Therefore  in  posterior  positions,  even 
when  with  a  small  fetus  the  shoulders  have  descended  into  the  pelvis 
(Fig.  198),  the  occiput  has  12.5  cm.  or  more  to  rise  before  it  can  pass 
over  the  edge  of  the  perineum.  Hence  the  difficulty  and  the  cause  for 
extension  and  stretching  of  the  perineum. 

The  molding  in  cases  of  persistent  occiput  posterior  is  apt  to  be  exces- 
sive. The  occipitomental  diameter  is  much  increased,  while  the  sub- 
occipitofrontal  is  lessened.  The  parietals  overlap  the  frontal  and  occipi- 
tal bones,  while  the  caput  is  large  and  is  generally  situated  over  the 
anterior  fontanelle,  directly  over  the  sagittal  suture,  as  the  head  has  been 
in  the  median  diameter  O.  P.  for  some  time.      This  excessive  mold- 


272  THE  MECHANISM  OF  LABOR 

ing  and  the  large  caput,  give  the  head  a  peculiarly  elongated  appearance 
(see  Fig.  201).  Often  the  excessive  molding  and  long-continued  press- 
ure is  fatal  to  the  fetus.  The  shoulders  and  body  are  born  by  exactly 
the  same  mechanism  as  in  those  cases  where  the  occiput  is  originally 
anterior. 

2.  Very  rarely  labor  terminates  spontaneously  in  another  way.  After 
the  occiput  has  rotated  to  the  hollow  of  the  sacrum,  its  advance  becomes 
in  some  manner  arrested,  and  the  forehead  proceeds  alone,  extreme 
extension  resulting.  The  chin  passes  first  under  the  pubic  arch,  when 
the  neck  is  crowded  up  against  the  arch,  and  the  head  is  born  by  flexion, 
the  mouth,  nose,  eyes,  forehead  and  occiput  passing  up  easily  in  succes- 
sion o\"ev  the  perineum,  as  flexion  increases.  In  other  words,  the  presen- 
tation becomes  converted  spontaneously  into  a  face,  and  delivery  takes 
place  with  the  chin  anterior  (see  Fig.  211).  This  favorable  outcome  is 
extremely  rare.  In  the  337  cases  of  persistent  occiput  posterior  on  record 
in  20,000  labors  at  the  Sloane  Hospital,  this  outcome  has  never  been 
seen.  (The  mechanism  in  face  presentations  will  be  considered  in  detail 
later.) 

3.  The  head  with  the  occiput  posterior  sometimes  becomes  impacted. 
This  occurs  when  the  fetus  is  large  or  the  pelvis  small,  or  where  the  liga- 
ments are  stiff  and  unyielding.  At  the  Sloane  Hospital  3  out  of  337  cases 
quoted  became  impacted. 

The  head,  with  the  occiput  persistently  posterior,  is  pushed  down 
through  the  pelvis.  The  head  becomes  sharply  flexed,  but  the  occiput 
is  prevented  from  rotating  by  some  obstruction,  or  the  flexion  occurs 
too  late.  The  neck  is  stretched  to  its  utmost,  and  the  occiput  is  pushed 
toward  the  coccyx.  To  reach  it  the  shoulders  must  follow  into  the 
pelvis,  for  the  posterior  pelvic  wall  from  the  promontory  of  the  sacrum 
to  the  coccyx  is  12.5  cm.  and  the  fetal  neck  is  only  7  cm.  Consequently 
both  the  body  and  the  head  of  the  fetus  are  crowded  into  the  pelvis  at 
once.  As  the  dorsosternal  diameter  or  depth  of  the  fetal  body  is  9.5 
cm.,  and  the  frontomental  diameter  or  depth  of  the  fetal  face  is  8.25 
cm.,  the  entire  diameter  of  17.75  cm.  (see  Fig.  203)  is  seeking  progress 
through  a  bony  canal,  the  widest  part  of  which  is  12  cm.  Hence  impac- 
tion occurs.  (When  spontaneous  delivery  occurs,  the  combined  diam- 
eters of  the  body  and  head  must  be  small  enough  to  pass  through  the 
pelvis.  That  is.  the  fetus  must  be  small  or  the  pelvis  large,  as  has  been 
said.) 

In  the  ^■ast  majority  of  cases  then,  in  posterior  positions  of  the  occiput, 
the  occiput  rotates  all  the  way  round  and  becomes  anterior,  the  labor 
differing  but  little  from  that  in  which  the  occiput  is  originally  anterior; 
while  in  a  very  small  proportion  of  cases,  roughly  about  4  per  cent.,^  the 
occiput  rotates  in  the  opposite  direction  to  the  sacrum,  a  persistent 
occiput  posterior  position  resulting. 

The  cause  of  this  anterior  rotation,  and  of  its  occasional  failure,  is  of 
the  greatest  interest. 

*  At  the  Sloane  Hospital  it  was  estimated  that  1.3  per  cent,  of  the  occiput  posterior  posi- 
tions failed  to  rotate  anteriorly  (about  1  in  8). 


MECHANISM  OF  POSTERIOR  POSITIONS  OF  THE   VERTEX     273 

In  the  consideration  of  the  mechanism  of  anterior  positions  of  the 
occiput  (see  page  261)  it  was  stated  that  the  most  satisfactory  explanation 
of  the  forward  rotation  of  the  occiput,  and  one  which  appUed  equally 
well  when  the  position  of  the  occiput  was  posterior,  was  found  in  the 
theory  which  attributes  to  the  pelvic  floor  the  power  of  rotating  forward 
under  the  pubic  arch  the  part  of  the  fetus  which  first  reaches  it,  provided 
this  action  is  not  otherwise  interfered  with. 

This  power  of  the  pelvic  floor  is  free  from  interference  only  when  the 
part  of  the  fetus  which  first  strikes  it  can  behave  like  a  ball. 

When  the  head  is  well  flexed  it  is  shaped  like  a  ball,  the  suboccipito- 
bregmatic  and  biparietal  diameters,  9.5  cm.,  and  9.25  cm.,  being  nearly 
equal;  and  when  the  head  is  thus  flexed  the  gutter  of  the  pelvic  floor 
has  the  power  to  turn  the  occiput  forward  whether  its  original  position 
was  anterior  or  posterior  to  the  transverse  diameter  of  the  pelvis. 


Fig.  203. — Impacted  occiput  posterior. 

When  the  head  is  not  well  flexed  it  is  not  like  a  ball  and  forward  rota- 
tion in  posterior  positions  of  the  occiput  is  prevented  by  the  spines  of  the 
ischia  striking  the  sides  of  the  sinciput.  If  flexion  was  complete  the 
sinciput  would  be  above  the  spine  of  the  ischium  and  its  backward  rotation 
would  not  be  prevented.  It  is  seen  from  this,  that  when  the  head  is  not 
flexed  so  that  its  shape  resembles  a  ball,  both  sinciput  and  occiput  have 
to  be  considered  in  the  rotation  of  the  latter,  and  that  when  the  occiput 
rotates  forward,  the  sinciput  must  rotate  backward,  and  in  poor  flexion 
this  is  prevented  by  the  spines  of  the  ischia.  In  this  condition,  then,  the 
fetal  head  simply  descends  with  occiput  posterior,  as  it  was  originally, 
and  the  pelvic  floor  acting  on  both  occiput  and  sinciput,  simply  has  the 
ability  of  making  the  long  diameter  of  the  head  coincide  with  the  direc- 
tion of  its  gutter;  or  extension  may  occur  instead  of  flexion,  and  the 
sinciput  strikes  the  pelvic  floor  first  and  is  rotated  forward  by  it,  while 
the  occiput  goes  backward. 
18 


274  THE  MECHANISM  OF  LABOR 

If  the  pelvic  floor  is  damaged  by  previous  overstretching  or  tearing, 
it  may  lose  its  power  of  causing  forward  rotation,  as  proved  by  the 
experiment  of  Dubois  and  verified  b\'  Edgar.  (These  experiments  were 
referred  to  when  discussing  anterior  rotation  of  the  fetal  head,  see  page  261, 
and  are  repeated  more  in  detail  here.) 

The  experiment  of  Dubois  is  classical.  "In  a  woman  who  had  died 
a  short  time  previously  in  childbed  the  uterus,  which  had  remained 
flaccid  and  of  large  size,  was  opened  up  as  far  as  the  cervical  orifice  and 
held  by  assistants  in  a  suitable  position  above  the  superior  strait.  The 
fetus  of  the  woman  was  then  placed  in  the  soft  and  dilated  uterus  in  the 
right  occipitoposterior  position.  Several  pupil  midwives,  pushing  it 
from  above,  readily  caused  it  to  enter  the  pelvis.  Much  greater  force 
was  needed  to  make  it  travel  over  the  perineum  anfl  clear  the  vulva,  and 
it  was  not  without  astoinshment  that  we  saw,  in  three  successi\c  attempts, 
that  when  the  head  had  traversed  the  external  genital  organs,  the  occiput 
had  turned  to  the  right  anterior  position,  while  the  face  was  turned  to 
left  and  to  the  rear.  In  a  word,  rotation  had  taken  place  as  in  natural 
labor.  We  repeated  the  experiment  a  fourth  time,  but  as  the  head  cleared 
the  vulva,  the  occiput  remained  posterior.  We  then  took  a  deadborn 
fetus  of  the  previous  night,  but  of  much  larger  size  than  the  preceding, 
and  placed  it  in  the  same  position  as  the  first,  and  twice  in  succession 
witnessed  the  head  clear  the  vulva,  after  having  executed  the  move- 
ment of  rotation.  Upon  the  third  and  following  essays,  delivery  was 
accomplished  without  the  occurrence  of  rotation.  Thus,  the  movement 
only  ceased  after  the  perineum  and  vulva  had  lost  the  resistance  which 
had  made  it  necessary,  or  at  best,  had  been  the  exciting  cause  of  its 
accomplishment." 

Edgar^  has  quoted  the  results  of  an  experiment  made  by  him,  in  which 
he  attached  a  swivel  and  a  yard  of  cord  to  the  head  of  a  dead  fetus,  one 
inch  in  front  of  the  small  fontanelle.  With  these  he  repeatedly  dragged 
the  fetus  through  the  pehis  of  a  woman  dead  after  recent  deli^■ery.  His 
findings  agree  entirely  with  those  of  Dubois.  Rotation  always  occurred 
until  the  pelvic  floor  lost  its  tonicity,  when  it  ceased.  He  sums  up  the 
experiment  as  follows:  "Given  the  normal  attitude  of  the  fetus  (extreme 
flexion  of  the  head),  and  good  expulsive  powers,  and  the  most  important 
remaining  condition  for  forward  rotation,  and  a  normal  mechanism 
is  a  firm  pelvic  floor." 

It  seems,  therefore,  that  forward  rotation  of  the  occiput  is  caused 
largely,  if  not  entirely,  by  the  resistance  of  the  pelvic  floor.  It  is  clear, 
however,  that  there  must  be  good  expulsive  pains,  that  flexion  must  be 
complete,  and  that  there  must  be  absence  of  mechanical  obstruction  to 
rotation. 

While  we  assign  to  the  resistance  of  the  pelvic  floor  the  chief  cause 
for  forward  rotation  of  the  occijjut,  we  can  summarize  the  causes  for 
failure  of  forward  rotation  or  posterior  rotation  of  the  occiput,  as  follows: 

>  The  Practice  of  Obstetrics,  1912,  p.  424. 


MECHANISM  OF  POSTERIOR  POSITIONS  OF  THE   VERTEX    275 

Anomalies  of  Force  or  Resistance. — Poor  expulsive  pains;  relaxed  pelvic 
outlet;  large  pelvis  or  small  fetal  head. 

Partial  Extension  Instead  of  Flexion. — Sinciput  first  reaches  resistance 
of  pelvic  floor  and  is  rotated  forward. 

Obstacles  to  Rotation. — Poor  flexion,  occiput  and  sinciput  reach  flopr 
at  about  same  time  and  rotation  prevented  by  spines  of  ischia;  different 
varieties  of  contracted  pelvis,  especially  an  obliquely  contracted  pelvis; 
timiors  of  the  pelvis;  a  compound  presentation. 

Under  normal  conditions  nature  has  arranged  that  the  occiput  shall 
always  rotate  forward,  and  it  is  only  when  marked  abnormalities  exist 
that  nature  fails. 

In  20,000  consecutive  labors  at  the  Sloane  Hospital  there  were  found 
337  persistent  occipitoposterior  positions.  Among  the  cases  tabulated 
were  poor  expulsive  pains,  21.9  per  cent.;  relaxed  pelvic  outlet,  32.3 
per  cent.;  small  fetus,  26.7  per  cent. 

Summary  of  Mechanism  in  Posterior  Positions. — The  R.  d.  P.  Position. 
—The  occipitofrontal  diameter  of  the  head  occupies  the  right  oblique 
diameter  of  the  pelvis.  Molding,  flexion,  and  descent  occur  as  in  the 
anterior  positions.  The  occiput  strikes  the  pelvic  floor  first  and  is 
rotated  anteriorly  to  the  pubic  arch  R.  0.  P.  to  R.  O.  to  R.  0.  A.  to  0.  A. 
through  135",  when  the  rest  of  the  labor  is  the  same  as  in  an  original 
R.  O.  A.  position.  This  occurs  in  96  per  cent,  of  the  cases. ^  Very  rarely, 
in  4  per  cent,  of  the  cases,^  owing  to  anomalies  of  force,  resistance,  or 
flexion,  or  to  abnormalities  of  the  pelvis  or  presentation,  the  occiput 
remains  posterior,  often  rotating  directly  to  O.  P.  Termination  of  labor 
takes  place  in  one  of  three  ways :  1 .  With  a  small  fetus  or  a  large  pelvis, 
the  head  descends  with  little  or  no  flexion  until  the  forehead  reaches 
the  pubic  arch.  Extreme,  tardy  flexion  then  occurs,  and  the  occiput  is 
pushed  up  over  the  perineum;  then  by  extension  the  brow,  nose  and 
mouth  slip  under  the  pubic  arch  and  the  head  is  born,  usually  tearing 
the  perineum. 

Restitution  and  external  rotation  of  the  occiput  to  the  right  occurs, 
as  the  left  or  anterior  shoulder  rotates  to  the  pubic  arch. 

The  anterior  or  left  shoulder  is  born  first,  followed  by  the  posterior, 
and  the  body  is  born  by  lateral  flexion  to  the  left. 

Exceptionally  the  posterior  shoulder  is  born  first. 

The  caput  is  usually  located  on  the  anterosuperior  angle  of  the  left 
parietal  bone.  It  may,  however,  be  found  on  the  posterosuperior  angle 
of  the  left  parietal,  as  in  an  original  R.  O.  A.  position,  or  directly  oyer 
the  anterior  fontanelle.  The  location  depends  upon  the  position  in  which 
the  head  was  longest  delayed.  If  long  in  the  R.  O.  P.  position  before 
rotation,  either  anteriorly  or  posteriorly  occurred,  the  caput  will  be  in 
the  location  first  indicated.  If  long  in  the  R.  O.  A.  position,  the  caput 
will  be  in  the  second  location  indicated;  while  if  long  directly  O.  P., 
the  caput  will  be  in  the  last  location  indicated.     The  parietal  bones 

1  Eighty-seven  per  cent,  at  the  Sloane  Hospital. 

2  Thirteen  per  cent  at  the  Sloane  Hospital. 


276  THE  MECHANISM  OF  LABOR 

will  be  found  overlapping  the  frontal  and  occipital  hones,  and  the  left 
parietal  overlapping  the  right. 

2.  The  presentation  is  converted  into  a  face,  and  delivery  takes  place 
with  the  chin  anterior.    This  is  very  rare. 

.3.  Impaction  occurs  after  extreme  flexion,  with  the  body  and  head  both 
forced  into  the  pelvis. 

The  L.  O.  P.  Position. — The  occipitofrontal  diameter  of  the  head  lies 
in  the  left  oblicjue  diameter.  Molding,  flexion  and  descent  occur  as  in 
the  anterior  positions^ 

The  occiput  strikes  the  pelvic  floor  first  and  is  rotated  anteriorly  to  the 
pubic  arch,  L.  O.  P.  to  L.  O.  to  L.  O.  A.  to  O.  A.  through  1.35°,  when 
the  rest  of  labor  is  the  same  as  in  an  original  L.  O.  A.  position.  This 
occurs  in  about  96  per  cent,  of  all  cases. 

Very  rarely  (in  4  per  cent,  of  all  cases)  anterior  rotation  fails. 

Labor  terminates  in  one  of  three  ways:  1.  With  a  small  fetus  or  a 
large  pelvis,  by  late  flexion,  followed  by  extension,  the  head  is  born  O.  P. 
Pestitution  and  external  rotation  of  the  occiput  to  the  left  occur,  as  the 
right  or  anterior  shoulder  rotates  to  the  pubic  arch. 

The  anterior  or  right  shoulder  is  born  first,  followed  by  the  posterior, 
or  the  posterior  shoulder  is  born  first  and  the  body  is  born  by  lateral 
flexion  to  the  right.  The  caput  is  located  on  the  anten)superior  angle 
of  the  right  parietal  bone;  or  on  the  })osterosuperior  angle  of  the 
right  parietal  bone;  or  directly  over  the  anterior  fontanelle,  the  location 
depending  upon  the  position  in  which  the  head  was  longest  delayed. 

2.  Delivery  by  the  mechanism  of  a  face  presentation  with  chin  anterior 
— very  rare. 

3.  Impaction  occurs,  after  extreme  flexion,  with  the  body  and  head 
forced  into  the  pelvis. 

Frequency  and  Results. — The  management  of  persistent  occipitopos- 
terior  positions  will  be  considered  later  (see  page  762)  but  the  frequency 
and  results  as  they  occurred  in  20,000  labors  at  the  Sloane  Hospital 
may  well  be  considered  now. 

In  2000  consecutive  labors  there  were  hy  actual  count  221  occipito- 
posterior  positions,  making  the  frequency  11.05  per  cent.  Estimated  on 
this  basis  there  would  have  been  found  in  the  20,000  labors,  2210  posterior 
positions. 

By  actual  count  in  the  20,000  labors  there  were  337  cases  of  yersiatcnt 
occipitoposterior  positions,  making  a  percentage  of  cases  failing  to  rotate 
13.1  per  cent. 

Prognosis. — The  results  of  labor  with  persistent  occipitoposterior 
positions  as  they  occurred  in  20,000  consecuti^'e  labors  at  the  Sloane 
Hospital  will  be  seen  from  the  following  table: 

Maternal  Mortality. — In  337  cases  of  persistent  occipitoposterior 
positions  in  20,000  labors. 

One  death  from  sepsis. 

Fetal  Mortality. — 78,  or  23.1  per  cent. 

Stillbirths,  45. 

Died  subsequently,  before  mother  left  hospital,  33. 


MECHANISM  OF  POSTERIOR  POSITIONS  OF  THE   VERTEX    277 

Causes  of. Fetal  Death. — Premature  labor,  31  cases;  difficult  labor,  23 
cases;  macerated  fetus,  14  cases;  toxemia  of  mother,  3  cases;  syphilis, 
2  cases;  hemorrhage  of  newborn,  2  cases;  accidental  hemorrhage,  3 
cases;  total,  78  cases. 

It  is  seen  from  the  above  that  the  prognosis  for  the  mother  is  excellent, 
although  the  fetal  mortality  is  considerable,  based  chiefly  on  the  fact 
that  the  labor  is  prolonged  and  more  manipulation  is  necessary. 

Treatment. — The  management  of  cases  with  persistent  occipitoposterior 
positions  of  the  vertex  will  be  discussed  more  fully  under  the  head  of 
Forceps  (see  page  762). 

Some  idea  of  the  treatment  needed  will  be  gained  from  the  following 
table  which  gives  the  method  of  delivery  in  the  337  cases  occurring  at 
the  Sloane  Hospital  in  20,000  consecutive  labors. 

Method  of  Delivery  in  337  Cases  of  Persistent  Occiiyitoposterior  Posi- 
tion of  the  Vertex. — As>  occipitoposterior,  196  cases;  rotation  by  hand  to 
O.  A.,  96  cases;  rotation  by  forceps  to-O.  A.,  42  cases;  craniotomy,  3 
cases;  podalic  version,  0;  total,  337  cases. 

The  deliveries  as  occipitoposterior  positions  occurred  chiefly  in  the 
earlier  portion  of  this  series,  as  in  recent  cases  the  posterior  positions 
have  usually  been  converted  to  anterior  positions  by  the  hand  or  the 
forceps. 

Considering  the  fact  that  posterior  positions  of  the  occiput  are  usually 
associated  with  imperfect  early  flexion,  an  increase  in  the  amount  of 
flexion  present  and  the  favoring  of  anterior  rotation  of  the  occiput  are 
the  objects  sought  by  the  obstetrician.  To  accomplish  flexion  some  have 
recommended  placing  the  women  on  the  side  toward  which  the  fetal 
back  is  directed.  Although  there  is  no  objection  to  a  trial  of  this  pro- 
cedure, the  author  has  never  felt  that  its  employment  proved  very 
efficacious. 

In  his  experience  two  methods  of  flexion  and  rotation  are  available: 
(1)  manual;  (2)  by  forceps. 

When  the  cervix  is  only  partly  dilated,  rotation  forward  of  a  posterior 
occiput  can  often  be  facilitated  by  introducing  two  fingers  through  the 
cervix,  and  then  increasing  the  flexion  of  the  head  and  turning  the 
posterior  fontanelle  toward  the  symphysis.  With  the  fingers  covered 
with  a  sterile  rubber  glove  and  with  strict  aseptic  precautions  this  may 
be  tried  with  little  risk.  If  this  method  fails  and  labor  is  unduly  pro- 
longed, the  author  believes  that  with  cervix  dilated  the  best  means  of 
dealing  with  occipitoposterior  positions  is  by  a  combination  of  manual 
rotation  and  forceps  delivery,  as  will  be  described  under  the  subject  of 
Forceps  (see  page  762).  Introducing  the  fingers  or  even  the  whole  hand 
into  the  vagina,  the  head  is  rotated  manually  so  that  the  posterior  fon- 
tanelle is  brought  as  near  the  symphysis  as  possible.  The  forceps  are 
then  applied  so  as  to  maintain  the  corrected  position  and  the  delivery 
is  completed.  As  will  be  described  later,  the  blade  of  the  forceps  first 
introduced  in  such  cases  is  that  corresponding  to  the  side  toward  which 
the  occiput  is  directed.  Some  obstetricians  recommend  podalic  version 
under  these  conditions  and  if  the  contra-indications  to  version  are  absent, 


27S 


THE  MECHAXISM  OF  LABOR 


this  procedure  may  he  justifiable,  hut  is  seldom  necessary,  as  is  shown  by 
the  fact  that  in  the  author's  series  of  ooT  cases  above  referred  to,  none 
were  delivered  l)y  podalic  version. 

THE   MECHANISM    OF   FACE   PRESENTATIONS. 

A  face  presentation  is  a  cephalic  presentation  with  the  head  in  sharp 
extension  (see  I"ig.  20-i). 

The  occiput  touches  the  back.  The  chin  is  the  most  dependent  por- 
tion and  corresponds  to  the  occiput  in  vertex  presentations. 

Face  presentations  occur  about  once  in  every  250  labors.  Pinard,' 
in  92,026  cases,  found  374  face  presentations;  1  in  250,  or  about  0.4  per 


Fig.  204. — Face  presentation. 


cent.  Edgar,-  in  2200  cases,  found  only  5  face  presentations;  1  in  440,  or 
about  0.22  per  cent. 

At  the  Sloane  Hospital,  in  20,000  labors,  there  have  occurred  77  face 
presentations;  1  in  260,  or  0.38  per  cent. 

The  majority  of  face  presentations  are  converted  vertex  presentations, 
and  occur  only  after  the  onset  of  labor,  when  some  mechanical  obstruc- 
tion causes  extension  or  prevents  flexion.  Indeed,  it  has  been  claimed 
that  face  presentations  never  exist  before  labor,  and  though  there  is 
the  best  authority  to  prove  that  occasionally  they  have  been  diagnosed 
previous  to  labor,  it  is  undisputed  that  such  cases  are  very  rare.    These 

1  Traite  du  palper  abdominal,  2me  ed.,  Paris,  1889,  pp.  32-50. 
-  The  Practice  of  Obstetrics,   1905,  p.  561. 


MECHANISM  OF  FACE  PRESENTATIONS 


279 


cases  are  called  primary  face  presentations,  while  those  occurring  during 
labor  are  called  secondary. 

Etiology. — The  causes  of  face  presentation  are  many.  In  the  jfirst 
place  conditions  tending  to  prevent  flexion  of  the  head,  sucji  as  coils 
of  cord  around  the  fetal  neck,  tumors  of  the  neck  such  as  goitre,  spastic 
contraction  of  the  muscles  of  the  back  of  the  neck,  marked  obesity  and 
dropsical  conditions  of  the  fetus — all  tend  to  produce  face  presentations. 


Fig.  205. — Pendulous  abdomen,  causing 
extension  of  the  head. 


Fig.  206. — The  same  case,  resulting 
in  a  face  presentation  as  the  uterus 
contracts  and  the  head  engages  in  the 
pelvis. 


In  the  second  place,  anything  favoring  extension  of  the  head,  such 
as  undue  mobility  of  the  fetus,  or  pressure  on  the  fetal  back,  as  by 
distended  maternal  bladder,  may  cause  a  face  presentation.  A  long 
head,  dolicocephalic,  may  cause  extension  if  the  occiput  catches  on  the 
brim  of  the  pelvis.  It  is  claimed,  however,  that  these  long  heads  are 
the  result  rather  than  the  cause  of  the  condition,  being  due  to  molding. 


280  THE  MECHANISM  OF  LABOR 

IVIathews  Duncan  called  attention  to  the  fact  that  an  oblique  position 
of  the  uterus  favors  extension  of  the  head  by  allowing  the  buttocks  of 
the  fetus  to  drop  forward,  thus  bringing  the  occiput  and  back  together 
(see  Figs.  205  and  206).  This  is  more  apt  to  occur  in  nudtigravida?  with 
lax  abdominal  walls.  Hence  the  greater  frequency  of  face  presentations 
in  multigravidie.  At  the  Sloane  Hospital,  of  the  77  face  presentations 
mentioned,  45,  or  58  per  cent.,  were  in  nudtigravida^,  while  82  were  in 
primigravida?. 

Anything  which  makes  engagement  of  the  head  difficult,  as  a  deformed 
pelvis  or  a  large  head,  tends  to  produce  a  face  presentation.  The  intro- 
duction of  the  largest-sized  dilating  bag  has  been  known  thus  to  convert 
a  vertex  into  a  face  presentation.  Hence  the  rule  at  the  ^-'loane  Hospital 
never  to  use  the  largest-sized  dilating  bag  excepting  in  breech  presenta- 
tions, or  in  such  cases  as  placenta  previa,  where  the  use  of  the  bag  is  to 
be  followed  by  podalic  version. 

Finally,  the  causes  of  malpresentations  in  general  will  favor  face 
presentations:  twins,  monstrosities,  especially  anencephalus,  hydramnios, 
tumors  of  the  pelvis,  and  prematurity.  Winckel^  says  that  in  30  per 
cent,  of  his  cases  hydramnios  was  present,  in  30  per  cent,  contracted 
pelvis,  and  in  22  per  cent,  coiling  of  the  cord  around  the  neck.  He 
regards  as.  the  most  frequent  causes  contracted  pelvis,  large  fetus,  and 
pendulous  abdomen.  At  the  Sloane  Hospital  only  12,  or  15.2  per  cent., 
of  the  77  face  presentations  were  in  deformed  pelves. 

Hirst^  says  that  all  face  cases  were  originally  brow  presentations. 

With  the  advent  of  labor  the  occiput  catches  on  the  brim  and  extreme 
extension  results.  The  eight  possible  positions  of  the  face  named  from 
the  chin  have  alreadv  been  mentioned  (page  249).  They  are  L.  M.  A., 
R.  M.  A.,  R.  M.  P.,  L.  M.  P.,  and  M.  A.,  M.  P.,  L.  M.,  R.  M. 

The  face  usually  occupies  the  right  oblique  diameter  of  the  pelvis, 
L.  M.  A.  or  R.  INI^  J'.,  the  other  positions  being  much  less  frequent. 
At  the  Sloane  Hospital  47  of  the  57  face  presentations  were  in  the  right 
oblique  diameter,  and  probabh'  a  higher  percentage  would  have  been 
found  if  examination  had  always  been  made  before  anterior  rotation 
occurred. 

This  usual  occupancy  by  the  face  of  the  right  oblique  is  not  surprising 
since  most  of  the  cases  were  originally  vertex  presentations,  where  the 
long  diameter  of  the  head  usually  occupies  the  right  oblique  diameter  of 
the  pelvis.  The  exact  frequency  of  the  different  positions  in  the  series 
of  77  cases  at  the  Sloane  Hospital  was  as  follows: 

Positio7is.--L.  M.  A.,  22;  R.  M.  A.,  20;  R.  M.  P.,  25;  L.  M.  P.,  5; 
L.  M.,  2;   R.  M.,  1;   M.  P.,  1;    not  stated,  1. 

'  Zur  Lehie  von  den  Gesichtslagen.  Klinische  Bcobachtungen  zur  Pathologie  der  Geburt. 
Rostock,  1869,  pp.  59-65. 

2  A  Text-book  of  Obstetrics,  1906,  p.  398. 


MECHANISM  OF  MENTO-ANTERIOR  POSITIONS  281 

MECHANISM    OF   MENTO-ANTERIOR   POSITIONS 
(L.    M.    A.    AND    R.    M.    A.). 

Diagnosis. — By  following  the  ordinary  methods  of  diagnosis,  abdom- 
inaJ  palpation  in  the  L.  ]M.  A.  position  shows  the  fetal  back  on  the 
right  and  posterior,  while  the  small  parts  are  on  the  left  and  anterior 
portion  of  the  mother's  abdomen. 

Palpation  of  the  lower  fetal  pole  shows  marked  prominence  of  the  fetal 
head  on  the  right  side  with  a  sulcus  between  the  occiput  and  the  fetal 
back,  while  the  fingers  can  be  depressed  deeply  on  the  left  side. 

Palpation  of  the  upper  fetal  pole  discloses  the  breech. 

Auscultation  of  the  fetal  heart  sounds  shows  the  point  of  greatest  inten- 
sity to  be  on  the  left  side  and  below  the  level  of  the  umbilicus. 

Vaginal  examination  is  most  important  in  the  diagnosis  of  face  piesen- 
tations.  At  the  beginning  of  labor  it  shows  the  presenting  part  high  up 
with  a  flattening  of  the  anterior  fornix.  As  the  cervix  becomes  dilated, 
the  characteristic  features  of  the  face  may  be  detected :  the  orbital 
ridges,  the  eyes,  the  nose,  mouth  and  chin,  lying  in  the  right  oblique 
diameter  of  the  pelvis. 

The  mouth,  with  the  hard  alveolar  processes,  is  the  most  important 
feature  in  differential  diagnosis. 

In  the  R.  M.  A.  positions  the  conditions  are  reversed.  The  back  lies 
to  the  left  and  posterior;  the  small  parts  lying  on  the  right. 

The  prominent  part  of  the  head  lies  at  the  left,  the  same  side  as  the 
back.  The  fetal  heart  sounds  are  heard  on  the  right,  and  vaginal  examina- 
tion shows  the  face  in  the  left  oblique  diameter  of  the  pelvis. 

Mechanism. — This  is  easily  understood  if  we  remember  that  the  chin 
takes  the  place  of  the  occiput  in  vertex  cases,  and  is  similarly  acted  upon. 

With  this  in  mind  we  find  labor  in  the  mechanism  following  the  same 
general  principles  as  in  vertex  cases,  but  with  important  differences,  as 
will  be  seen. 

The  mechanism  of  labor  in  L.  M.  A.  and  li.  M.  A.  positions  in  face 
presentation  consists  in:  engagement,  molding,  extension,  descent, 
internal  rotation,  flexion,  restitution,  and  external  rotation. 

Engagement. — Occasionally  a  face  presentation  occurs  before  labor, 
but  usually  only  after  labor  begins.  The  diameter  presenting  at  the 
pelvic  brim  is  the  frontomental.  This  is  so  small  (8.25  cm.)  that  it 
could  easily  engage  in  any  diameter. 

The  fact  that  it  usually  engages  in  the  right  oblique  seems  to  confirm 
the  theory  that  face  cases  were  originally  vertex  presentations.  The 
head  engages  readily,  owing  to  the  small  diameter  presenting  and  when 
the  widest  transverse  diameter,  the  biparietal,  is  at  the  brim  it  is  already 
deep  in  the  pelvis.  The  distance  from  the  parietal  boss  to  the  chin  is 
greater  than  from  the  parietal  boss  to  the  occiput.  Hence  when  well 
engaged  a  face  is  lower  in  the  pelvis  than  a  vertex  would  be  (see  Figs. 
207  and  208).     INIolding,  extension,  and  descent  take  place  together. 

Molding. — Usually  this  is  slight  as  the  diameters  are  small.  The 
bones  of  the  face  are  closely  united  and  are  capable  of  little  change 


282 


THE  MECHANISM  OF  LABOR 


in  position  owing  to  early  ossification.  When  the  i)elvis  is  small  the  head 
is  flattened  at  the  cranial  vault,  the  frontal  bones  increased  in  convexity, 
and  the  supra-occipital  region  pushed  back  (see  Fig.  209). 


Fig.  207. — Face  presentation.     Head  low  in  pelvis  when  parietal  boss  is  at  the  brim. 


Fig.  208.— Vertex  presentation.    Head  high  in  the  pelvis  when  parietal  boss  is  at  the  brim. 


MECHANISM  OF  MENTO -ANTERIOR  POSITIONS 


283 


The  anterior  cheek  will  present  first,  the  left  in  L.  M.  A.  and  the  right 
in  R.  M.  A.,  and  will  show  a  capnt,  but  this  will  vary  in  location  accord- 
ing to  the  position  in  which  the  face  longest  remains.  If  there  is  much 
delay  after  rotation  of  the  chin,  the  entire  face  may  be  involved  in  the 
caput. 

Extension. — ^This  corresponds  to  flexion  in  vertex  cases,  and  is  brought 
about  by  the  same  agencies. 

The  head  presents  a  two-armed  lever,  the  longer  from  the  occipito- 
atloid  articulation  to  the  occiput  and  the  shorter  from  this  articulation 
to  the  chin  (see  Fig.  184).  Counter-pressure  from  below  tends  to  push 
up  the  longer  arm  of  the  lever,  causing  extension.  Moreover,  the  force 
exerted  by  the  uterine  and  abdominal  muscles  through  the  body  of  the 
fetus  acts  more  directly  on  the  chin  than  on  the  occiput,  also  producing 
extension. 


Fig.  209. — Face  presentation. 

In  vertex  presentations  the  same  forces  tend  to  produce  flexion.  Here 
the  long  arm  of  the  lever  is  in  front  of  the  articulation.  Compare  Fig. 
176. 

As  in  vertex  presentations,  flexion  is  necessary  in  order  to  allow  the 
small  diameter,  the  suboccipitofrontal,  10.5  cm.,  to  present,  instead  of 
the  larger  occipitofrontal  diameter,  11.5  cm.;  so  in  face  presentations 
extension  is  even  more  necessary  in  order  to  allow  the  small  fronto- 
mental  diameter,  8.25  cm.,  to  present,  instead  of  the  very  large  occipito- 
mental diameter,  13.25  cm. 

Descent. — This  is  also  brought  about  by  the  same  factors  as  in  vertex 
cases,  and  is  favored  by  molding  and  extension,  although  little  molding 
is  usually  necessary.  Owing  to  the  small  diameter  presenting,  8.25 
cm.,  descent  would  be  very  rapid  if  extension  were  complete  from  the 
beginning.  This  is  rarely  so,  and  descent  takes  place  little  by  little 
with  extension.    However,  as  has  been  seen,  the  forces  of  the  uterine  and 


284  THE  MECHANISM  OF  LABOR 

abdominal  muscles  act  to  poor  mechanical  achaiitage  throiitih  the  fetal 
body.    Therefore  descent  is  generally  slow. 

Internal  Rotation. — As  extension  increases,  the  head  slowly  descends 
until  the  chin  reaches  the  pelvic  floor.  J3y  the  resistance  of  the  levatores 
ani,  it  is  then  rotated  forward  under  the  pubic  arch,  as  is  the  occiput 
in  vertex  presentations.  Rotation  is  not  as  easy,  however,  as  in  vertex 
cases.  In  the  first  place  the  distance  from  the  trunk  to  the  chin,  5  cm., 
is  less  than  the  distance  from  the  trunk  to  the  occiput,  7  cm.  The  lateral 
wall  of  the  pelvis  is  9  cm.  deep,  so  that  the  chin  has  4  cm.  to  descend 
after  complete  extension  before  reaching  the  pelvic  floor,  while  the 
occiput  in  vertex  cases  has  only  2  cm.  to  descend  after  full  flexion.  There- 
fore the  chin  must  be  pushed  down  that  much  farther  than  the  occiput 


Fig.  210. — Face  presentatiou.     Mouth  and  nose  emerging. 

before  rotation  can  occur.  Again  the  chin  is  very  small  and  is  not  acted 
upon  as  readily  as  is  the  larger  occiput  in  vertex  presentations.  Still 
further,  until  the  head  is  low  enough  in  the  pelvis  for  the  occiput  to  pass 
the  promontory,  rotation  is  prevented,  except  with  a  very  small  head 
or  in  a  large  pelvis,  by  the  occiput  hitting  on  the  promontory.  P'or 
these  reasons  labor  is  slow. 

Flexion. — After  the  chin  reaches  the  pubic  arch  it  passes  under  it  for 
about  1  cm.  and  then  stops.  As  the  length  of  the  neck  from  the  sternum 
to  the  chin  is  5  cm.  and  the  anterior  pelvic  wall  is  4  cm.,  it  can  go  no 
farther  until  the  descent  of  the  shoulders,  which  is  not  possible  until 
the  head  is  born.  The  expulsive  forces  now^  act  on  the  forehead  which 
advances  (flexion),  and  the  mouth,  nose,  eyes,  forehead  and  occiput  sue- 


MECHANISM  OF  MENTO-ANTERIOR  POSITIONS 


285 


cessively  appear  and  are  pushed  up  over  the  perineum  (see  Figs.  210 
and  211).  The  neck  is  crowded  up  against  the  pubic  arch  tightly,  until 
the  occiput  is  over  the  perineum.  It  will  be  observed  that,  contrary  to 
the  usual  statements,  the  diameters  emerging  through  the  vulvar  outlet 
are  not  much  larger  than  in  normal  vertex  cases.  They  are  the  mento- 
frontal,  the  cervicobregmatic,  and  the  cervico-occipital,  8.25  cm.,  10 
cm.,  and  10  cm.  respectively.  Much  tearing  of  the  perineum  is  not  neces- 
sary, if  the  chin  is  born  before  flexion  begins,  and  the  neck  is  crowded  well 
up  against  the  pubic  arch.  The  measurement  at  the  Sloane  Hospital, 
of  100  babies  from  one  to  thirteen  days  old,  gave  the  following  average 
diameters:  mentofrontal,  8.24  cm.;  cervicobregmatic,  10.02  cm.;  cervico- 
occipital,  10.07  cm. 


Fig.  211. — Face  presentation.     Face  emerging. 

Restitution  and  External  Rotation. — As  soon  as  the  head  is  fully  born  it 
drops  back  toward  the  anus  of  the  mother.  The  chin  immediately  turns 
slightly  to  the  side  to  which  it  originally  pointed,  to  the  left  in  L.  M.  A. 
and  to  the  right  in  R.  M.  A.,  untwisting  itself,  as  it  has  rotated  from 
left  to  right  or  right  to  left  as  the  case  may  be,  and  the  shoulders  have 
not  followed — restitution . 

After  a  short  interval  the  chin  turns  decidedly  to  the  side  to  which 
it  originally  pointed,  to  the  left  in  L.  M.  A.,  to  the  right  in  R.  M.  A.,  as 
the  shoulders  rotate  from  right  to  left  or  from  left  to  right— external 
rotation. 

Birth  of  the  Shoulders  and  Body. — The  long  diameter  of  the  shoulders 
enters  the  pelvis  in  the  opposite  oblique  diameter  from  that  previously 


286  THE  MECHANISM  OF  LABOR 

occupied  l)y  the  face.  The  anterior  shoulder  first  strikes  tlie  i)elvic  floor 
and  rotates  anteriorly  to  the  pubic  arch,  and  the  shoulders  are  born 
either  anterior  or  posterior  first,  as  in  vertex  cases.  The  body  is  born 
by  lateral  flexion. 

It  will  be  observed  that  after  the  i^irth  of  the  head,  conditions  differ  in 
nowise  from  those  of  a  vertex  presentation  with  the  occiput  posterior,  an 
L.  M.  A.  corresponding  exactly  to  an  R.  O.  P.  position,  and  an  IX.  M.  A. 
to  an  L.  O.  P.  The  occiput  and  the  chin  each  restitutes  and  rotates 
to  the  side  to  which  it  originally  pointed,  but  in  opposite  directions. 
It  may  simplify  matters  for  the  student  if  he  will  remember  that  the 
bodv  of  the  fetus  has  the  same  position  in  L.  M.  A.  and  \\.  O.  P.;  in 
R.  M.  A.  and  L.  O.  P.;  in  L.  M.  P.  and  R.  O.  A.;  and  in  R.  M.  P.  and 
L.  O.  A.  Or  anterior  positions  of  the  chin  correspond  to  posterior  posi- 
tions of  the  occiput  in  the  same  oblique,  and  vice  versa.  After  a  face 
delivery  the  features  of  the  fetus  are  markedly  distorted,  but  in  twelve 
to  twenty-four  hours  this  "caput"  has  disappeared  and  the  features 
are  normal  again. 

Summary  of  Mechanism,  L.  M.  A. — The  long  diameter  of  the  face 
occupies  the  right  oblique  diameter  of  the  pelvis.  The  position  of  the 
body  is  that  of  an  R.  O.  P. ;  molding,  extension  and  descent  occur  together, 
little  molding  being  necessary.  The  chin  strikes  the  pelvic  floor  late 
in  the  second  stage,  and  is  rotated  forward  and  inward  to  the  pubic 
arch — L.  IM.  A.  to  ]\I.  A.  It  passes  under  the  pubic  arch  and  then  stops. 
The  anterior  part  of  the  neck  is  crowded  up  against  the  arch  and  flexion 
begins  as  the  forehead  and  occiput  are  pushed  forward,  and  slide  up  over 
the  perineum,  while  mouth,  nose,  eyes,  forehead,  bregma  and  finally 
occiput  emerge  over  the  perineum.  The  head  now  drops  back  toward 
the  mother's  anus.  The  chin  turns  slightly  and  then  decidedly  toward 
the  left  in  restitution  and  external  rotation.  The  shoulders  enter  the 
pelvis  in  the  left  oblique  diameter,  the  left  shoulder  rotates  anteriorly 
to  the  pubic  arch,  and  the  shoulders  are  born  anterior  or  posterior  first, 
and  the  body  by  lateral  flexion  to  the  left  (birth  of  the  body  as  in  R.  O.  P. 
persistent).  After  labor  little  molding  of  the  facial  bones  is  seen,  but 
the  cranial  vault  may  be  flattened.  The  caput  is  on  the  left  cheek, 
or  it  may  in\"olve  the  whole  face,  if  there  has  been  much  delay  after 
rotation. 

Mechanism  of  R.  M.  A. — The  long  diameter  of  the  face  occupies  the 
left  oblique  diameter  of  the  pelvis.  The  position  of  the  body  is  that  of 
an  L.  O.  P.  Molding,  extension,  and  descent  occur  together.  The 
chin  strikes  the  pelvic  floor  (late)  and  rotates  forward  and  inward  to 
the  pubic  arch — R.  ]\I.  A.  to  ]\I.  A.  The  chin  passes  under  the  arch  and 
the  head  is  born  by  flexion,  the  chin  turning  to  the  right  in  restitution 
and  external  rotation.  The  shoulders  enter  the  pelvis  in  the  right  oblique 
diameter,  and  the  right  rotates  anteriorly  to  the  pubic  arch.  The  bwly 
is  born  by  lateral  flexion  to  the  right  (birth  of  the  body  as  in  an  I/.  0.  P. 
persistent).    The  caput  is  on  the  right  cheek. 


MECHANISM  OF  MENTOPOSTERIOR  POSITIONS  287 

THE  MECHANISM  OF  MENTOPOSTERIOR  POSITIONS 
(R.  M.  P.  AND  L.  M.  P.). 

These  posterior  positions  of  the  chin  occur  with  almost  as  great  a 
frequency  as  do  the  anterior  positions.  R.  M.  P.  and  L.  M.  A.  positions, 
with  the  face  in  the  right  obHque  diameter  of  the  pelvis  are  most  fre- 
quent; while  L.  M.  P.  and  R.  M.  A.  positions,  in  the  left  oblique  diameter, 
are  rare.  In  our  series  of  77  face  cases  R.  M.  P.  occurred  25  times; 
L.  M.  P.,  5  times. 

The  causes  of  the  posterior  position  are  the  same  as  those  of  the 
anterior,  most  being  converted  vertex  cases,  and  the  rest  the  result  of 
abnormalities  of  development  or  position  in  mother  or  fetus. 

Diagnosis. — The  exact  conditions  in  face  presentation  with  chin 
posterior  are  seldom  made  out  by  external  palpation  alone.  Abdominal 
palpation  shows  certain  characteristics  of  face  presentation  in  the  marked 
sulcus  between  occiput  and  fetal  back,  but  in  the  mentoposterior  posi- 
tions the  small  parts  are  not  as  distinct,  and  the.  fetal  heart  sounds  are 
usually  transmitted  through  the  back  of  the  fetus.  It  is  the  vaginal 
examination  which  usually  determines  the  position,  disclosing  the  face 
in  the  right  oblique  diameter,  less  often  in  the  left  with  chin  posterior. 

Mechanism. — In  the  vast  majority  of  cases  the  mechanism  is  prac- 
tically the  same  as  in  anterior  positions.  Engagement  followed  by  mold- 
ing, extension  and  descent — ^all  are  the  same.  Extension  must  be  more 
complete  and  descent  lower  in  order  that  the  chin  may  reach  the  pelvic 
floor.  When  this  is  accomplished  the  chin  rotates  anteriorly  to  the 
pubic  arch,  and  the  rest  of  the  labor  is  the  same  as  in  anterior  positions. 
Labor  is  apt  to  be  longer  and  interference  is  more  often  necessary,  for 
the  chin  must  be  lower  before  rotation  can  occur,  and  of  course  this  is 
through  a  greater  distance,  135°  rather  than  45°.  Aside  from  this  the 
outcome  is  as  favorable  as  in  anterior  positions. 

In  over  99  per  cent,  of  all  cases  this  is  true.  In  about  1  per  cent,  of 
the  cases,  however,  anterior  rotation  of  the  chin  does  not  occur,  but  the 
chin  rotates  posteriorly  into  the  hollow  of  the  sacrum;  further  advance 
becomes  impossible  and  impaction  occurs.^ 

The  cause  of  the  backward  rotation  of  the  chin  is  incomplete  extension 
of  the  head.  As  a  consequence  the  sinciput  reaches  the  peh'ic  floor  first 
rather  than  the  chin,  and  is  therefore  rotated  anteriorly  to  the  pubic 
arch,  while  the  chin  is  necessarily  carried  backrs'ard.  It  is  claimed  that 
even  where  the  chin  is  originally  anterior,  this  same  result  may  occa- 
sionally follow,  the  sinciput  being  carried  all  the  way  around  to  the 
pubic  arch,  while  the  chin  becomes  posterior. 

With  the  chin  remaining  posterior  in  a  face  presentation,  it  is  generally 
agreed  that  the  birth  of  a  live  child  is  impossible.  Indeed,  unless  the 
fetus  be  very  small  any  birth  is  impossible,  for  impaction  nuist  occur. 

The  reason  for  this  is  plain.    The  length  of  the  fetal  neck  from  sternum 

1  At  the  Sloane  Hospital  out  of  the  77  face  presentations,  1  or  a  little  less  than  1^  per  cent, 
became  impacted  after  posterior  rotation  of  the  chin.  It  must  be  remembered,  however, 
that  impaction,  when  threatened,  was  generally  prevented  by  operative  measures. 


288 


THE  MECHANISM  OF  LABOR 


to  chin  is  only  5  cm.  This  can  easily  subtend  the  anterior  pelvic  wall 
4  cm.,  but  is  entirely  too  short  to  subtend  the  posterior  pelvic  wall,  12.5 
cm.  to  the  tip  of  the  coccyx,  and  12.5  cm.  more  to  the  edge  of  the  peri- 
neum (see  Fig.  212).  Consequently  the  progress  of  the  chin  is  arrested 
after  the  neck  is  stretched  to  its  utmost.  The  occiput  is  jammed  against 
the  back,  and  the  wedge  thus  formed  by  the  body  anfl  the  head  is  crowded 
down  into  the  pelvis.  It  cannot  pass  through,  for  the  combined  diam- 
eters of  the  head  and  the  thorax,  19  cm.  (dorsosternal  of  the  thorax, 
9.5  cm.,  and  suboccipitobregmatic  of  the  head,  9.5  cm.),  is  far  greater 
than  the  widest  diameter  of  the  pelvis,  12  cm.  Hence  the  inevitable 
impaction. 

Summary  of  Mechanism,  R.  M.  P. — The  face  occupies  the  right 
oblique  diameter  of  the  pehis,  the  position  of  the  body  is  that  of  an 
L.  O.  A. 


Fig.  212. — Impacted  face.      Cbin  posterior. 

Engagement,  molding,  extension  and  descent  occur.  In  the  xnst 
majority  of  cases  the  chin  reaches  the  pelvic  floor  and  anterior  rotation 
to  the  pubic  arch  takes  place,  R.  M.  P.  to  R.  M.  to  R.  M.  A.  to  M.  A. 
After  the  R.  M.  A.  position  is  reached,  labor  progresses  as  though  this 
had  been  the  original  position.  The  caput  is  on  the  right  cheek,  if  the 
longest  delay  was  before  rotation;  and  o^•e^  the  whole  face,  if  longest  after 
rotation  is  complete  (to  ]M.  A.).  In  the  small  minority  of  cases  owing  to 
incomplete  extension  the  chin  rotates  into  the  hollow  of  the  sacrum  jM.  P. 
and  impaction  occurs. 

Summary  of  Mechanism,  L.  M.  P. — The  face  is  in  the  left  oblique 
diameter  of  the  pelvis.    The  position  of  the  body  is  that  of  an  R.  O.  A. 

Engagement,  molding,  extension  and  descent  occur.  In  the  vast 
majority  of  cases,  internal  rotation  to  the  pubic  arch,  L.  M.  P,  to  L.  j\I. 
to  L.  M.  A.  to  ]\I.  A.  takes  place.    After  the  position  L.  M.  A.  is  reached. 


MECHANISM  OF  MENTOPOSTERIOR  POSITIONS  289 

labor  progresses  as  though  this  had  been  the  original  position.  The  caput 
is  on  the  left  cheek  or  over  the  whole  face,  according  as  to  whether  the 
delay  was  longest  at  L.  M.  P.  or  M.  A.  In  the  small  minority  of  cases 
the  chin  rotates  to  M.  P.  and  impaction  occurs. 

Prognosis. — While  many  cases  of  face  presentation  with  chin  anterior 
deliver  themselves  spontaneously  and  with  relatively  little  delay,  still 
face  presentations  are  always  viewed  with  considerable  anxiety,  and  this 
is  especially  so  when  at  the  beginning  of  labor  the  chin  is  found  in  a 
posterior  position. 

The  results  as  they  occurred  in  the  series  of  77  cases  at  the  Sloane 
Hospital  were  as  follows : 

Maternal  Mortality. — There  were  2  maternal  deaths,  2.59  per  cent. 
One  died  from  ruptured  uterus  and  1  from  sepsis. 

Fetal  Mortality. — In  the  77  deliveries  there  were  16  stillbirths  and  11 
died  before  the  mother  left  the  hospital,  making  a  total  fetal  mortality 
of  27,  or  35  per  cent.,  but  of  these  6  were  monstrosities,  2  were  macerated, 
2  were  too  premature  to  be  viable,  leaving  only  a  fetal  mortality  of  17, 
or  22  per  cent.,  which  could  be  assigned  to  the  presentation  and  delivery. 
Of  these  16  children  lost,  13  were  lost  on  account  of  the  difficult  labor, 
and  3  from  prolapsed  cord. 

Treatment. — Considering  the  fact  that  the  delivery  of  a  face  with 
chin  anterior  is  so  nearly  normal,  and  all  others  abnormal,  it  naturally 
follows  that  the  only  face  presentations  to  be  left  to  nature  are  those 
with  chin  in  anterior  positions,  and  in  all  others  some  conversion  is 
indicated. 

In  mentoposterior  positions  the  object  most  desired  is  a  marked 
flexion  by  which  the  face  with  chin  posterior  is  converted  into  a  vertex 
with  occiput  anterior.  Many  methods  of  accomplishing  this  have  been 
suggested.  The  method  recommended  by  Schatz  consisted  in  an  attempt 
to  flex  the  head  by  external  manipulation,  raising  and  pushing  the  shoulder 
in  the  direction  of  the  occiput  and  the  breech  in  the  opposite  direction, 
thus  favoring  the  descent  of  the  occiput. 

This  method  is  only  applicable  during  pregnancy  or  the  early  stage 
of  labor  and  has  never  proved  efficient  in  the  author's  hands. 

In  a  certain  number  of  cases,  with  two  fingers  of  one  hand  in  the  vagina 
and  through  the  cervix,  and  the  other  hand  on  the  abdomen,  the  fetal 
head  can  be  flexed  into  a  vertex.  If  this  fails  it  is  perfectly  justifiable, 
with  the  patient  under  anesthesia,  to  insert  the  whole  hand  into  the 
vagina  and  then  with  the  fingers  of  that  hand  through  the  cervix  and  the 
other  hand  on  the  abdomen  to  push  up  the  chin  and  flex  the  head  into  a 
vertex  presentation  with  occiput  anterior;  a  method  whose  principle 
was  recommended  by  Baudelocque  in  1789. 

If  conversion  of  a  face  into  a  vertex  is  impossible  and  the  chin  still 
remains  posterior,  the  best  procedure  is  a  podalic  version,  provided 
version  is  not  contra-indicated  on  account  of  a  tonic  condition  of  the 
uterus.  The  use  of  the  forceps  in  delivery  of  the  face  will  be  discussed 
later.  If  conversion  to  a  vertex  is  impossible  and  podalic  version  is 
contra-indicated,  the  face  usually  should  be  allowed  to  descend  to  the 
19 


290  THE  MECHANISM  OF  LABOR 

outlet  of  the  pelvis,  with  the  hope  that  either  by  the  hand  or  the  forceps 
the  chin  can  then  be  rotated  anteriorly.  If  this  fails,  craniotomy  is  usually 
the  procedure  of  choice.  At  a  certain  stage  of  the  labor,  with  chin  per- 
sistently posterior,  Cesarean  section  should  theoretically  be  considered, 
although  the  author  has  never  met  with  a  case  in  which  he  thought  it 
indicated. 

The  methods  of  delivery  practised  in  the  series  of  77  face  presentations 
were  as  follows: 

Delivered  as  face,  without  instrimients,  43.  In  some  of  these  the 
anterior  rotation  of  the  chin  was  assisted  manually. 

Delivered  as  face,  with  forceps,  1 1 . 

Delivered  as  vertex  after  partial  cephalic  version,  8. 

Delivered  as  breech  after  internal  poflalic  version,  14. 

Delivered  by  craniotomy  after  impaction,  1. 

A  few  precautions  should  be  emphasized  in  the  management  of  face 
presentations.  It  is  desirable  to  maintain  the  membranes  intact  until 
the  dilatation  of  the  cervix  is  complete,  hence  the  need  of  care  in  vaginal 
examinations.  After  the  rupture  of  the  membranes,  care  should  be 
observed  that  the  eyes  of  the  fetus  are  not  injured  by  the  examining 
fingers,  and  in  the  birth  of  the  head  and  neck  care  should  be  taken  not 
to  crowd  the  neck  of  the  child  too  forcibly  against  the  pubic  arch  lest 
the  larynx  and  trachea  be  injured. 


THE  MECHANISM  OF  BROW  PRESENTATIONS. 

A  brow  presentation  is  a  cephalic  presentation  midway  between  a 
vertex  and  a  face  (see  Fig.  213).  The  head  is  neither  well  flexed  nor 
well  extended,  but  only  sufficiently  extended  to  make  the  brow  the  most 
dependent  portion. 

BroAv  presentations  have  the  same  frequency  as  have  face  presenta- 
tions. They  are  practically  all  transitional  from  vertex  to  face  presen- 
tations, and  it  is  probable  that  even  the  primary  face  cases  were  at  one 
time  brow  presentations. 

Brow  presentations  are  nearly  alwa\'s  converted  spontaneously  into 
either  face  or  vertex  presentations.  Occasionally  they  are  persistent 
and  only  then  are  they  of  importance. 

Persistent  brow  presentations  are  very  rare.  x\ccording  to  Williams 
they  occur  about  1  to  1500  or  2000  cases.  Von  Weiss^  claimed  them 
occurring  as  often  as  1  to  1000.  In  Guy's  Hospital  in  24,582  labors 
there  were  14  brow  presentations,  1  to  1756.^  Edgar,^  in  2200  cases 
previously  quoted,  found  persistent  brow  presentations  only  three 
times,  1  to  733,  or  0.13  per  cent. 

In  20,000  consecutive  labors  at  the  Sloane  Hospital  there  were  34 

1  Zur  Behandlung  der  Gcsichts  und  Stirnlagen,  Volkmann's  Sammlung  Klin.  Vortrage, 
N.  F.  No.  74. 

2  Quoted  from  Hirst,  Text-book  of  Obstetrics,  1900,  p.  399. 
2  Practice  of  Obstetrics,  1905,  p.  555. 


^,*-!**sat%aR 


MECHAXISM  OF  BROW  PRESENTATIONS 


291 


persistent  brow  presentations,  or  0.17  per  cent;  15  occurred  in  primigravidse 
and  19  in  multigravidee ;  4  occurred  in  deformed  pelves. 

Brow  presentations  result  from  the  same  general  causes  as  do  those 
of  the  face,  and  as  in  face  presentations  the  most  frequent  positions  are 
those  in  which  the  long  diameter  of  the  head  lies  in  the  right  oblique 
diameter  of  the  pelvis;  L.  F.  A.  and  R.  F.  P.  (Y.  standing  for  "frontal" 
or  brow). 

Diagnosis. — A  brow  presentation  offers  even  more  difficulties  in  diag- 
nosis by  abdominal  palpation  than  does  the  face,  although  the  same 
general  characteristics  are  present.  In  the  palpation  of  the  fetal  pole, 
however,  the  prominence  of  the  head  on  the  side  of  the  fetal  back  and  the 
sulcus  between  the  two  are  much  less  marked  than  in  the  typical  face 
presentation. 


Fig.  213. — Brow  presentation. 

The  prominence  of  the  chin  on  the  side  of  the  small  parts  is  often 
palpable.  The  diagnosis  is  usually  made  by  vaginal  examination  and 
is  based  on  feeling  at  one  end  of  one  of  the  oblique  diameters,  the  large 
fontanelle  and  at  the  other  the  orbital  ridges,  eyes  and  nose.  The  frontal 
suture  can  be  felt  extending  along  this  oblique  diameter. 

Mechanism. — Strictly  speaking  there  is  none.  The  presentation 
is  transitional  only.  In  the  rare  cases,  where  the  presentation  is  per- 
manent, labor  is  usually  arrested,  and  impaction  occurs. 

The  reason  for  this  is  clear.  The  diameter  presenting  is  the  largest 
possible  diameter  of  the  head,  the  occipitomental,  13.25  cm. 

This  is  too  large  to  pass  through  the  normal  pelvis,  the  largest  avail- 
able diameter  of  which  is  12  cm. 

If  the  head  is  very  small,  it  is  occasionally  crowded  through  without 


292 


THE  MECHANISM  OF  LABOR 


any  niechanisni,  that  is,  if  the  occipitomental  diameter  is  small  enough 
to  pass  throu.gli  the  contracted  portions  of  the  pelvis  unchanged.  This 
occurs  only  in  premature  births. 

It  is  claimed  that  very  rarely  with  a  small  head  and  after  frightful 
molding  there  is  a  mechanism  in  l)row  cases  which  may  result  in  spon- 
taneous birth  as  a  brow.  In  this  the  brow  corresponds  to  the  occiput 
in  ^•ertex,  or  the  chin  in  face  presentations.  Engagement  occurs  in  one 
of  the  oblique  diameters  of  the  pelvis. 

The  head  is  molded  so  that  the  mento-occipital  diameter  is  less  and 
the  occipitofrontal  greater.  The  head  neither  becomes  more  nor  less 
extended  in  its  descent,  as  the  two  arms  of  the  lever  are  practically  equal 
(see  Fig.  214).    The  brow  reaches  the  pelvic  floor  still  the  most  dependent 


Fig.  214. — Brow   presentation, 
of  lever  practically  equal. 


Arms 


Fig.  215. — Molding  in  brow  presentation. 


portion,  and  is  rotated  forward  to  the  pubic  arch.  The  forehead,  orbital 
ridges  and  the  root  of  the  nose  appear  at  the  vulva.  The  superior  maxil- 
lary bone  lodges  against  the  pubic  arch  and  the  head  is  born  by  extreme 
flexion,  the  brow  followed  by  the  bregma  and  the  occiput  appearing  over 
the  perineum. 

The  molding  shows  a  decrease  in  the  mento-occipital  and  an  increase 
in  the  occipitofrontal  diameter.  The  caput  is  situated  between  the 
anterior  fontanelle  and  the  root  of  the  nose  (see  Fig.  215). 

It  may  be  observed  that  the  mechanism  is  similar  to  that  of  a  persis- 
tent occiput  posterior,  where  at  the  last,  flexion  is  not  complete,  and  where, 
owing  to  the  small  size  of  the  fetus,  the  head  is  not  born  by  late  exten- 
sion (the  usual  method)  but  by  continued  flexion,  the  small  body  descend- 
ing into  the  pelvis  to  allow  this. 


MECHANISM  OF  BROW  PRESENTATIONS  293 

Indeed,  it  might  be  simpler  to  consider  all  these  rare  so-called  brow 
deliveries  as  persistent  occipitoposterior  positions,  terminating  by 
continued  flexion  rather  than  by  late  extension,  because  of  the  small 
size  of  the  fetus. 

At  any  rate  it  must  not  be  forgotten  that  a  spontaneous  birth  with 
the  brow  presenting  is  very  rare,  and  can  only  take  place  when  the 
fetus  is  relatively  very  small  or  the  molding  is  excessive.  At  any 
time  the  condition  may  be  converted  spontaneously  into  a  vertex  or  a 
face  presentation,  or  impaction  may  occur.  Consequently  the  delivery 
of  a  brow  presentation  as  such  is  never  to  be  expected.  It  is  better  for 
practical  purposes  to  think  of  brow  presentations  as  transitional,  and  if 
permanent,  as  impossible  of  delivery. 

In  the  34  cases  of  persistent  brow  presentation,  occurring  in  20,000 
labors  at  the  Sloane  Hospital,  none  was  delivered  as  a  brow,  either  spon- 
taneously or  instnunentally. 

Prognosis. — In  brow  presentation  the  prognosis  depends  largely 
upon  the  skill  of  the  obstetrician  in  recognizing  and  early  correcting  the 
condition  when  the  brow  shows  a  tendency  to  become  persistent. 

In  the  series  of  34  brow  presentations,  in  20,000  consecutive  deliveries 
at  the  Sloane  Hospital,  there  was  one  maternal  death  from  rupture  of 
the  uterus.  This  gave  a  maternal  mortality  of  2.9  per  cent.  The  total 
fetal  mortality  in  this  series  was  17,  or  50  per  cent.,  but  only  10,  or  29.4 
per  cent.,  were  due  to  the  presentation  or  delivery.  The  details  of  the 
total  fetal  mortality  are  as  follows: 

Difficult  labor,  impaction,  etc.,  9;  macerated  fetus,  4;  prolapsed  cord, 
1;   premature,   nonviable,   1;   hemorrhage  of  newborn,   1;   anomaly  of 

^t,  1;  total,  17. 

Treatment. — A  brow  presentation  of  a  full-term  child  should  never 
be  left  to  nature  to  deliver  as  a  persistent  brow.  There  are  three  methods 
of  choice  in  dealing  with  the  delivery. 

1 .  Flex  to  a  vertex. 

2.  Extend  to  a  face  with  chin  anterior. 

3.  Perform  podalic  version. 

As  previously  stated,  a  brow  presentation  is  usually  transitional,  and 
if  it  is  seen  that  it  is  being  gradually  converted  by  nature  into  a  face 
presentation,  with  chin  anterior,  it  is  well  to  leave  the  case  alone.  If, 
however,  the  brow  tends  to  be  persistent  as  a  brow,  the  methods  of  con- 
version mentioned  above  should  be  tried  in  that  order.  A  conversion 
to  a  vertex  with  the  fingers  of  one  hand  through  the  cervix  and  the  other 
hand  on  the  abdomen  is  often  possible,  if  too  much  molding,  as  a  brow 
has  not  already  taken  place,  and  is  the  best  outcome.  Next  to  this 
is  a  conversion  to  a  face  with  chin  anterior,  simply  assisting  nature  in 
her  usual  procedure.  Failing  in  this,  if  version  is  not  contra-indicated 
on  account  of  a  tonic  condition  of  the  uterus,  internal  podalic  version 
is  a  much  better  procedure  than  extension  to  a  face  with  chin  posterior, 
with  its  associated  difficulties  of  delivery.  However,  in  rare  instances, 
with  version  contra-indicated,  this  may  be  the  only  alternative.  Some 
cases  with  or  without  the  help  of  the  forceps  may  be  rotated  at  the  out- 


204  THE  M EC II A \ ISM  OF  LABOR 

let,  Imt  ill  iiKiiiy  iiistimces  (Taiiiutoiny  must  he  resorted  to.    Pubiotoiny 

has  heeii  performed  suceessfully  for  this  (•oii(liti(»ii  hut  the  author  does 

not  feel  hke  recoininen<nnf;  it. 

The  methods  of  (K-hvery  employed  in  the  series  of  thirty-four  brow 

presentations  just  referred  to  were  as  follows: 

As  a  \ertex,  17)  .  ,:  ,.  ,         ,    ,.  .        ^^ 

.        e  ,,>Atter  partial  cephalic  version,  J(>. 

As  a  face,        Dj  '  ^ 

As  a  breech  after  internal  podalic  version,  5. 

Impacted  brow — cram"otom\',  'A. 

BREGMA  PRESENTATIONS  (PRESENTATION  OF  THE  ANTERIOR 

FONTANELLE). 

Bregma  presentations  are  sometimes  described  as  shown  in  Fig.  182. 
The\-  are  midway  between  brow  and  vertex  presentations,  and  are 
reall\-  oidy  vertex  presentations  with  poor  flexion  of  the  head.  They 
have  the  same  causes  as  have  face  and  brow  presentations,  and  probably 
occur  (juite  frequently.  The  mechanism  is  that  of  vertex  presentation, 
but  it  is  the  occipitofrontal,  rather  than  the  suboccipitofrontal  diameter 
which  presents,  11.,")  cm.  instead  of  10..")  cm.,  so  the  labor  is  harder, 
and  tearing  of  the  soft  parts  much  more  frequent.  ^Moreover,  as  the 
occiput  and  sinciput  descend  on  the  same  level,  rotation  does  not  take 
place  easily,  and  the  head  may  remain  in  the  pelvis  for  hours  in  posterior 
position  of  the  occiput  without  rotating. 

It  seems  unnecessary,  however,  to  describe  these  separately  as  bregma 
presentations,  but  rather  as  vertex  presentations  with  poor  flexion. 

Poor  flexion  of  the  head  in  vertex  piesentations  with  the  occiput  ^os-^ 
terioi  is  recognized  as  one  of  the  causes  of  long,  difficult  labor  with  lack 
of  anterior  rotation. 

THE   MECHANISM    OF   BREECH   PRESENTATIONS. 

A  breech  presentation  is  one  in  which  the  pelvic  end  of  the  fetal  ovoid 
presents  at  the  cervix.    It  is  a  longitudinal  presentation. 

A  "complete"  breech  presentation  is  one  in  which  the  fetus  retains 
its  normal  attitude  with  the  legs  and  thighs  flexed  on  the  abdomen, 
the  feet  consequenth'  presenting  at  the  cervix  with  the  buttocks  (see 
Fig.  185).    This  is  also  called  a  "full"  breech  presentation. 

A  "frank"  breech  presentation  is  one  in  which  the  thighs  only  are 
flexed,  the  legs  being  extended  along  the  abdomen  of  the  fetus  (see  Fig. 
186).    This  is  also  called  a  "breech  with  extended  legs." 

A  foot  or  a  knee  may  prolapse,  giving  rise  to  the  terms  "foot"  and 
"knee"  presentations,  but  as  prolapse  of  a  lower  extremity  in  nowise 
changes  the  mechanism  or  treatment  from  that  of  a  normal  breech  pre- 
sentation, these  terms  are  of  little  importance. 

Frequency. — Pinard.^  who  quotes  the  largest  series  of  cases  on  record, 
found  in  10(),()(K)  labors  of  all  kinds  3301  breech  presentations,  3.3  per 

'  Loc.  cit. 


MECHANISM  OF  BREECH  PRESENTATIONS  295 

cent.,  or  about  1  to  30.    In  labors  at  term  only,  however,  he  found  the 
trequency  less,  or  only  about  1  in  60. 

Edgar/  in  his  2200  labors,  found  82  breech  presentations,  3.7  per  cent 
or  about  1  to  26.  '' 

The  findings  at  the  Sloane  Hospital  correspond  more  nearly  with  those 
ot  Ldgar  than  with  those  of  Pinaid.  In  20,000  labors,  actually  90  252 
births,  on  account  of  multiple  births,  there  were  835  breech  presentations 
4.12  per  cent.,  or  about  1  to  24.  In  17,401  labors  at  term  there  were  492 
breech  presentations,  2.25  per  cent.,  or  1  to  35.  In  the  2599  premature 
labors  there  were  343  breech  presentations,  13.2  per  cent.,  or  about  1 
to  /.o. 

beSe'term*""^*^'  ''^^^'^'  ^^^^  '^'''^'"^  frequency  of  breech  presentations 
Failure  of  the  "law  of  accommodation"  already  mentioned  is  chiefly 
responsible  for  breech  presentations.  Normally  the  fetal  ovoid  best 
fits  the  uterme  cavity  when  it  lies  with  the  cephalic  end  downward 
Any  change  m  shape  of  the  uterine  cavity  or  of  the  fetal  ovoid  tends  to 
disturb  the  workings  of  this  law,  and  may  result  in  a  breech  presentation 
or  some  other  presentation  less  frequent. 

Thus  breech  presentations  occur  more  frequently  in  multigravid^ 
with  lax  abdommal  and  uterine  walls;  in  hydramnios;  in  deformities 
ot  the  uterus  with  fibroid  tumors;  and  in  placenta  previa-in  all  of 
which  conditions_  the  normal  shape  of  the  uterine  cavity  is  disturbed- 
also  m  prematurity;  with  twins;  with  monstrosities;  and  with  dead  or 
macerated  fetuses-conditions  in  which  the  fetal  ovoid  is  abnormal  in  shape 
Anything  preventing  free  engagement  of  the  head,  such  as  a  deformed 
^  T  l?""  ci-'f  ^^^?^  ^''''^^'  ^^''^'  ^°  P^^^^ce  a  breech  presentation. 
Hn.n^t«?  in  presentations  mentioned  as  occurring  at  the  Sloane 

Hospital,  490,  or  nearly-  60  per  cent.,  were  in  multigravid^;  h^-dramnios 
IZ^T/  '?  4;  fibroids  m  8;  placenta  previa  in  5;  septate  uterus  and 
'^f '?^,f^^^^°^'  by  which  the  shape  of  the  uterus  was  distorted,  each  1 

q  iV  ;''l?-'''  ^^  P''  ''^^•'  ^.^'  ^^'^"^^  ^'^^  premature;  in  76,  or  about 
9  per  cent  tu'ins  were  present;  in  63,  or  7.5  per  cent.,  the  fetus  was  dead 
or  macerated;  and  m  5  fetal  monstrosities  occurred.  In  107  or  over  12 
per  cent.,  the  pelvis  was  deformed. 

K.;'^'l!''  tT^"^'"  presentations,  there  are  eight  possible  positions  of  the 
breech.  These  are  named  from  the  positions  of  the  sacrum,  as  has  ah-eadv 
been  e-xplained  (see  page  250;.  According  to  the  findings  at  the  Sloane 
Hospital  the  fetal  back  lies  much  more  frequently  anterior  than  posterior 
In  80/  breech  presentations,  m  which  the  position  was  accurateh-  deter- 
7Z'  Tl,  7'q  s/ero-anterior,  while  only  91  were  sacroposterior  posi- 
tions. The  Lb.  A  positions  numbered  399,  and  the  R.  S.  A.  numbered 
317,  showing  that  the  fetal  back  was  more  commonly  on  the  left  side  nf 
the  mother  s  abdomen.^   The  sacroposterior  positions^-ere  abou  teqn  lly 

Sr  s'r  in4'5"'      '       ^'^'  "^''  ^'  ^-  ^-  ^^^^^  ^^^  P°^^^^^-  - 

1  Practice  of  Obstetrics,  1905,  p.  580. 


296  THE  MECHANISM  OF  LABOR 

111  comi)lete  breech  presentations  the  anteroposterior  diameter  is 
greater  (although  more  compressible)  than  is  the  transverse  or  bi tro- 
chanteric. The  positions  L.  S.  A.  and  U.  S.  P.  results  from  a  selection 
by  this  larger  diameter,  of  the  larger  diameter  of  the  pelvis — the  right. 
This  is  shown  in  the  series  of  807  breech  presentations  at  the  Sloane 
Hospital,  in  which  the  L.  S.  A.  and  R.  S.  P.  numbered  444,  while  the 
K.  S.  A.  and  L.  S.  P.  numbered  363. 

In  frank  breech  presentations  the  anteroposterior  diameter  is  not  the 
longer,  and  hence  this  reason  for  seeking  the  right  oblique  diameter  of 
the  pelvis  does  not  hold,  but  the  complete  breech  presentation  is  much 
more  common  than  the  frank  breech — 504,  as  compared  with  331  in  the 
complete  series  of  S3o  cases  abo\e  quoted — therefore  the  general  rule 
holds. 

Diagnosis. — In  a  breech  presentation  abdominal  palpation  detects 
the  fetal  back  on  one  side  of  the  mother's  abdomen  and  the  fetal  small 
parts  on  the  other.  Palpation  of  the  lower  fetal  pole  immediately  arouses 
attention  by  the  absence  of  the  hard  head  usually  felt  there. 

Palpation  of  the  upper  fetal  pole  discloses  the  hard,  round,  movable 
object,  which  a  little  experience  will  enable  the  obstetrician  to  recognize 
at  once  as  the  fetal  head. 

Auscultation  of  the  fetal  heart  sounds  locates  the  point  of  greatest 
intensity  at  or  above  the  level  of  the  umbilicus  and  on  the  left  or  right 
side  of  the  mother's  abdomen,  according  as  the  fetal  back  is  on  the  left 
or  the  right  side. 

Vaginal  examination  in  the  early  stage  of  labor  detects  the  absence  of 
the  hard,  round  head,  and  relatively  high  position  of  the  presenting  part. 
With  the  cervix  dilated  the  spines  of  the  sacrum,  the  tuberosities  of  the 
ischiimi  and  the  anus  are  felt.  If  the  membranes  have  ruptured  and  the 
presenting  part  has  descended  into  the  pelvis  the  characteristics  of  the 
genitals  can  be  detected.  In  the  later  stages  of  labor  the  presenting 
part  becomes  edematous  and  the  breech  with  its  anus  may  present  some 
of  the  characteristics  of  the  face  with  its  mouth. 

A  careful  attention,  however,  to  the  following  differential  features, 
will  usually  enable  the  diagnosis  to  be  made  without  difficulty. 

Breech vs. Face. 

Head  in  upper  abdomen.  Head  in  lower  abdomen.    ' 

Anus.  Small,  no  bony  ridges.  Mouth.  Larger,  bonj-  alveolar  ridges. 

Sphincteric  action.  No  sphincteric  action. 

Meconium  discharged.  No  meconium  discharged. 

Sharp  spines  of  the  sacrum.  No  such  projections. 

Among  all  these  differential  features  the  sacnun  is  the  most  important. 
If  you  feel  the  sacrum  you  have  a  hreech. 

5s'ot  infrequently  before  the  vaginal  examination  has  been  made  there 
has  been  a  dark  discharge  on  the  \'uh'a  pad  which  can  be  recognized  at 
once  as  meconium,  and,  taken  with  the  feel  of  the  hard,  round  mass  in 
the  upper  abdomen,  serves  as  a  verification  of  the  diagnosis  of  a  breech 
presentation. 


MECHANISM  OF  BREECH  PRESENTATIONS  297 

In  a  complete  breech  presentation  and  in  a  footling  presentation  the 
examining  finger  may  first  reach  a  foot  and  the  question  naturally  arises, 
"Is  it  a  foot  or  a  hand?"  Attention  to  the  following  differential  features 
will  often  prove  of  value: 

Foot vs. Hand. 

At  right  angles  to  leg.  In  line  -witli  arm. 

Toes  short  and  all  in  straight  line.  Fingers    longer;    thumb    almost    at 

right  angles  to  fingers. 
Heel  felt.  No  such  projection. 

Among  these  differential  features  the  heel  is  the  most  important.  If 
you  feel  a  Jieel  you  have  a  foot. 

Mechanism  of  Breech  Presentation  L.  S.  A.  and  R.  S.  A. — The  mechan- 
ism of  complete  and  frank  breech  presentation  is  practically  the  same, 
though  the  treatment  is  different,  as  will  be  discussed  later. 

Engagement. — The  back  of  the  fetus  is  directed  toward  one  iliopectineal 
eminence,  and  the  bitrochanteric  diameter  lies  in  the  opposite  oblique 
diameter  of  the  pelvis.  Engagement  does  not  take  place  until  late  in 
labor,  for  although  the  bony  diameter  of  the  breech  is  small,  bitrochan- 
teric, 8.75  cm.,  the  breech  itself  is  irregular  and,  until  compressed,  large. 
Hence  it  rides  high  until  well  molded. 

Molding. — The  soft  parts  are  compressed,  and  the  flexion  of  the  legs 
and  thighs  increased.  There  is  no  real  caput,  although  there  is  edema 
and  discoloration  of  the  anterior  buttock,  or  of  the  scrotum  in  males. 
An  extremity  if  prolapsed  becomes  discolored  and  swollen. 

Descent. — Labor  usualh'  is  slow,  as  the  breech,  soft  and  irregular,  not 
fitting  well  into  the  pelvis,  makes  a  poor  dilator  for  the  cervix.  The 
membranes  are  apt  to  rupture  prematurely  because  of  this  irregularity 
of  the  breech  and  the  movements  of  the  feet  in  complete  breech  presen- 
tations. 

Internal  Rotation. — The  anterior  or  lower  buttock  first  reaches  the 
pelvic  floor  and  rotates  anteriorly  to  the  pubic  arch. 

Birth  of  Hips. — The  hips  are  now  born  in  one  of  three  ways:  both 
together,  the  posterior  first  followed  by  the  anterior,  or  the  anterior  first 
followed  by  the  posterior.  The  hips  are  so  small  that  they  can  easily 
be  born  together,  especially  in  a  frank  breech.  In  a  complete  breech 
usually  the  anterior  foot  prolapses  at  this  tiriie,  followed  by  the  birth 
of  the  anterior  hip.  Then  the  posterior  foot  and  hip  follow  over  the 
perinemn. 

(This  mechanism  is  rarely  observed  unassisted  at  the  Sloane  Hospital 
as  it  is  the  practise  there  for  the  obstetrician  to  deliver  the  anterior  foot 
as  it  appears  at  the  vulva,  and  thus  to  favor  the  birth  of  the  anterior 
hip  first.)     (See  Treatment). 

As  the  posterior  hip  passes  over  the  perineum  the  body  is  bent  laterally 
upward,  corresponding  to  the  curve  of  the  birth  canal.  After  the  birth 
of  the  hips  these  fall  downward  toward  the  mother's  anus  and  the  body 
straightens  out.  The  body  is  rapidly  born  until  the  shoulders  appear 
at  the  pelvic  brim,  which  occurs  at  about  the  time  when  the  imibilicus 
is  born. 


29S 


THE  MECHANISM  OF  LABOR 


Birth  of  the  Shoulders. — The  shoulders  enter  the  pelvis  in  the  same 
oblique  diameter  as  did  the  hips.  The  anterior,  being  lower  in  the  pelvis, 
first  strikes  the  pelvie  Hoor  and  rotates  to  the  pubic  arch.  Again,  as  in 
cephalic  presentations,  the  shoulders  may  be  born  in  one  of  three  ways: 
anterior  first  followed  by  posterior,  posterior  first  followed  by  anterior, 
or  both  together.  The  tliameter  of  the  shoulders  is  large,  12.25  cm.,  so 
that  rarely  will  both  shoulders  be  born  together.  Unassisted  the  anterior 
will  probably  be  born  first,  because  of  the  weight  of  the  body  dragging 
it  downward.  It  is  said  that  among  savages  the  mother  generally 
reaches  down  and  lifts  the  body  of  her  child  upward  in  an  attempt  to 
embrace  it,  thus  probably  assisting  the  posterior  shoulder  out  first. 
The  custom  among  obstetricians  is  divided.  At  the  Sloane  Hospital 
the  body  is  lifted  with  the  object  of  first  freeing  the  posterior  shoulder 


Fig.  216. — Normal  delivery  of  the  after-coming  head.    Occiput  anterior.    Head  well  flexed. 


(see  Treatment).  The  arms  are  normally  born  still  flexed.  Occasionally 
they  become  extended,  delaying  the  birth  of  the  head  (see  Abnormalities 
of  Breech  Delivery,  page  713). 

Birth  of  the  Head. — This  is  the  critical  part  of  breech  deliveries,  as  the 
head  presents  longer  diameters  than  the  body  unless  well  flexed.  It  is 
difficult  to  describe  the  normal  mechanism  in  the  birth  of  the  after-coming 
head,  for,  except  in  large  pelves  or  with  small  fetuses,  this  mechanism  is 
always  assisted  by  the  obstetrician.  At  the  Sloane  Hospital,  except  in 
the  conditions  mentioned,  the  mechanism  unassisted  is  never  observed. 
Indeed,  it  is  the  duty  of  the  obstetrician  in  e^-ery  breech  delivery  to  cavse 
the  mechanism  most  favorable  for  delivery  to  occur.  (This  will  be 
explained  fulh'  under  Treatment.) 

As  the  shoulders  are  born  the  head  presents  at  the  brim  of  the  pelvis. 
Xormally  the  head  is  well  flexed,  asJjecause  of  uterine  pres>ure  from 


MECHANISM  OF  BREECH  PRESENTATIONS  299 

above,  the  longer  pole  of  the  lever,  the  sinciput  is  pushed  down  (see  Fig. 
216).  Consequently  it  is  the  suboccipitofrontal  diameter,  10.5  cm.,  which 
presents.  This  can  enter  the  pelvis  in  any  diameter,  the  narrowest  diam- 
eter at  the  brim  being  11  cm.  If  the  shoulders  remain  as  they  were 
born,  directly  anteroposterior,  the  head  will  enter  the  pelvis  directly 
transversely,  L.  0.  or  R.  O.  The  rotation  of  the  occiput  anteriorly  or 
posteriorly  is  now  influenced  chiefly  by  the  position  oj  the  body.  The 
weight  of  the  arms  and  legs  being  chiefly  on  the  side  of  the  abdomen, 
causes  this  to  turn  downward,  and  the  back  to  turn  upward.  The  occi- 
put naturally  follows,  rotating  anteriorly  to  the  pubic  arch.  The  weight 
of  the  body  falling  downward  increases  the  flexion.  The  occiput  catches 
on  the  pubic  arch  and  is  arrested.  The  sinciput  is  pushed  onward  and 
up  over  the  perineum,  chin,  mouth,  nose,  eyes  and  forehead  successively 
emerging.    And  the  head  is  born  by  continued  flexion. 

If  the  body  begins  to  pronate  immediateh*  after  the  birth  of  the 
shoulders,  the  long  diameter  of  the  head  enters  the  pelvis,  not  in  the 
transverse  diameter,  but  in  one  oblique,  and  with  the  continued  prona- 
tion of  the  body  the  occiput  rotates  to  the  pubic  arch.  If  the  head  is 
large  or  not  well  flexed,  that  is,  if  there  is  any  difficulty  in  engagement 
in  the  transverse  diameter,  the  body  will  turn,  thus  bringing  the  head 
into  the  oblique.  It  is  probable  that  it  enters  the  oblique  oftener  than 
in  the  transverse.  It  is  readily  seen  how  the  obstetrician,  by  causing 
anterior  rotation  of  the  back,  can  almost  surely  secure  anterior  rotation 
of  the  occiput. 

Posterior  Rotation  of  the  Occiput. — Very  rarely  the  body  supinates, 
and  the  occiput  rotates  into  the  hollow  of  the  sacrum.    This  occurs  either 
from  some  manipulation  of  the  body  of  the  child,  or  because  of  some  » 
abnormality  of   the  pelvis,  by  which   the   occiput   is  prevented   from  ^ 
rotating  anteriorly. 

Delivery  of  the  head  takes  place  in  one  of  two  ways.  If  the 
head  is  well  flexed,  uterine  pressure  from  above  and  the  weight  of  the 
body  dragging  from  below,  forces  the  sinciput  down,  so  that  the  chin 
passes  under  the  pubic  arch,  and  the  mouth,  nose,  eyes,  and  forehead 
pass  under  the  pubic  arch  first  (see  Fig.  217).  The  head  is  born  by  con- 
tinued flexion,  the  back  of  the  child  approaching  the  back  of  the  mother. 

If  the  head  is  extended,  the  long  diameter,  the  mento-occipital,  13.25 
cm.,  presents  at  the  outlet.  This  cannot  be  born.  The  chin  catches  above 
the  pubic  arch  and  is  held  there  while  pressure  from  above  forces  the 
occiput  down  first  and  pushes  it  up  over  the  perineum,  the  occiput, 
fontanelles,  forehead,  eyes,  nose,  mouth,  and  lastly  chin  successively 
appearing  over  the  perineum.  The  head  is  born  by  late  extension  (see 
Fig.  218),  the  abdomen  of  the  child  approaching  the  abdomen  of  the 
mother. 

In  the  first  condition  it  is  evident  that  the  obstetrician  could  be  of 
assistance  by  niaking  traction  doTvniward;  in  the  second,  by  traction 
upward. 

Summary  of  Mechanism,  L.  S.  A. — ^The  back  is  directed  toward  the 
left  iliopectineal  eminence.     The  bitrochanteric  diameter  is  in  the  left 


300 


THE   MECHAXISM  OF  LABOR 


oblique  diameter  of  the  pelvis.     Engagement  occurs  late  followed   by 
molding.     Descent  is  slow.     The  left  or  anterior  hip  rotates  anteriorly 


Fig.  217. —  Occiput  posterior.     Head  born  by  continued  flexion 


Fig.  218. — Occiput  posterior.     Head  bom  by  late  extension. 


MECHANISM  OF  BREECH  PRESENTATIONS 


301 


to  the  pubic  arch,  and  the  hips  are  born  by  lateral  flexion  to  the  left 
(of  the  child)  both  together,  the  anterior  first,  or  the  posterior  first. 
The  shoulders  enter  the  same  diameter  as  did  the  hips,  the  left  oblique. 
The  left  shoulder  rotates  anteriorly,  and  the  shoulders  are  born  unassisted 
anteriorly  first,  followed  by  the  posterior;  if  assisted,  possibly  the  pos- 
terior first;  occasionally,  if  small,  both  together.  The  head,  well  flexed, 
enters  the  pelvis  in  the  opposite  diameter  from  that  by  which  the  shoulders 
and  hips  entered,  transversely  or  in  the  right  oblique,  according  to  the 
position  of  the  body,  and  the  occiput  rotates  anteriorly  chiefly  from 
the  pronation  of  the  body.  The  occiput  catches  on  the  pubic  arch  and 
the  head  is  born  by  flexion. 

Rarely  the  occiput  rotates  into  the  hollow  of  the  sacrum,  because  of 
the  supination  of  the  body  or  from  some  obstacle  to  forward  rotation. 
Delivery  takes  place  in  one  of  two  ways. 
With  good  flexion  the  forehead  passes 
under  the  pubic  arch  and  the  head  is 
born  by  continued  flexion,  the  back  of 
the  child  approaching  the  back  of  the 
mother.     With  the  head  extended,  the 
chin  catches  above  the  pubic  arch,  and 
the  occiput  is  pushed  forward,  the  head 
being  born  by  extension,  the  abdomen 
of  the  child  approaching  the  abdomen  of 
the  mother. 

Mechanism  of  R.  S.  A. — The  back  is 
directed  toward  the  right  iliopectineal 
eminence  and  the  bitrochanteric  diameter 
is  in  the  right  oblique  diameter  of  the 
pelvis.  ^Molding  and  descent  occur. 
The  right  hip  rotates  anteriorly.  The 
body  is  born  by  lateral  flexion  to  the 
right  (of  the  child).  The  shoulders  enter 
the  right  oblique  diameter,  and  the  right 
shoulder  rotates  anteriorly.  The  head 
enters  the  pelvis  transversely,  or  in  the 
left  oblique  diameter,  and  rotates  ante- 
riorly; occasionally  posteriorly. 

Mechanism  of  R.  S.  P.  and  L.  S.  P. — This  is  exactly  similar  to  that 
of  the  anterior  positions.  The  back  is  directed  to  the  right  or  left  sacro- 
iliac joint.  The  anterior  hip  and  shoulder  rotate  to  the  pubic  arch,  when 
the  conditions  are  the  same  as  in  the  original  anterior  positions. 

The  head  after  a  breech  delivery  is  not  molded  at  all.  This  fact  is 
very  noticeable  (see  Fig.  219). 

(The  abnormalities  of  mechanism  in  breech  deliveries  will  be  con- 
sidered under  Treatment.) 

Prognosis. — Maternal. — The  maternal  prognosis  of  breech  presenta- 
tions is  excellent,  although  it  should  be  recognized  that  the  risk  of  lacera- 
tion of  the  perineum  is  much  greater  than  in  vertex  presentation,  and  in 


Fig.    219. 


-Breech  delivery, 
not  molded. 


Head 


302  THE  MECHANISM  OF  LABOR 

frank  breech  presentations,  especially  in  primigravidte,  even  complete 
lacerations  of  the  perinenin  are  not  very  infrequent. 

In  the  8:i")  breech  i)resentations,  occurring  in  20,000  consecutive  labors 
at  the  Sloane  Hospital,  there  were  7  deaths,  or  0.8  per  cent.,  although  none 
of  these  deaths  were  due  to  the  i)resentation.    The  causes  were  as  follows: 

From  sepsis,  2. 

Eclampsia,  2. 

Toxemia  of  ])regnancy,  2. 

INIalignant  endocarditis,  1. 

In  4  cases  there  occurred  a  complete  laceration  of  tlie  perineum. 
Fetal  Prognosis. — Tlie  fetal  prognosis  in  breech  presentation  is  always 
less  favorable  than  in  presentations  of  the  vertex,  and  for  many  reasons. 
Many  of  the  children  are  premature.  Some  of  the  serious  complica- 
tions of  ])regnancy  and  labor  requiring  artificial  delivery,  as  placenta 
previa,  are  associated  with  breech  presentation.  Furthermore,  abnor- 
malities of  mechanism  and  delay  in  the  delivery  of  the  head  not  infre- 
(jucntly  associated  with  lireech  ])resentation  add  to  the  fetal  risk, 
esi)ecially  in  ])rimigravid{T^. 

In  the  series  of  s;^5  breech  presentations  at  the  Sloane  Hospital,  there 
was  a  complete  fetal  mortality,  including  abortions  and  macerated  fetuses, 
of  302,  or  36  per  cent.,  which  was  <livided  as  follows: 

Fetal  deaths  from  difficult  labor,  48,  or  5.7  per  cent. 

Prematurity  and  early  fetal  death,  230,  or  27.5  per  cent. 

Other  causes,  24,  or  2.8  per  cent. 

Total,  36  per  cent. 
The  conditions  grouped  under  the  head  of  "other  causes  "  mentioned 
above,  will  be  seen  from  the  following  table: 

Accidental  hemorrhage 8 

Placenta  previa 3 

Eclampsia 2 

Immaturity  (twins) 2 

Anomalies 4 

Hemorrhage  of  newborn 2 

Bronchopnciinionia 2 

Acute  infection  of  liver 1 

ToiixX 24 

It  is  seen  from  the  abo^•e  that  while  the  general  fetal  mortality  was 
36  })er  cent.,  less  than  6  per  cent,  was  due  to  the  delivery  itself. 

Treatment. — As  the  fetal  danger  is  greater  in  breech  than  in  vertex 
deliveries  and  the  labors  are  usually  longer  and  more  difficult  for  the 
mother,  it  is  usually  wise  to  attempt  the  conversion  of  the  breech  to  a 
vertex  presentation  before  labor. 

In  multigravidae  with  lax  abdominal  and  uterine  walls  this  conversion 
can  often  be  accomplished  with  ease  by  external  manipulation  alone, 
i.  e.,  by  external  version.  With  the  woman  on  her  back  and  with  the 
abdomen  uncovered,  the  obstetrician  gently  pushes  the  fetal  head  toward 
the  brim  of  the  pelvis,  while  he  })ushes  the  breech  in  the  opposite  direc- 
tion, as  described  in  the  chapter  on  Version  (see  page  769). 


MECHANISM  OF  BREECH  PRESENTATIONS  303 

If  the  patient  is  a  primigravida  with  tense  or  very  fat  abdominal 
wall,  or  if  the  fetus  is  very  large  and  the  breech  is  low  in  the  pelvis, 
external  cephalic  version  is  much  more  difficult  and  sometimes  without 
an  anesthetic  is  impossible.  Under  an  anesthetic  the  version  is  usually 
easy  and  the  difficulty  consists  only  in  maintaining  the  corrected  presen- 
tation. If  the  head  is  placed  well  within  the  brim  of  the  pelvis  and  there 
is  no  abnormality  present,  the  fetus  will  often  stay  in  cephalic  presenta- 
tion. Disappointments,  however,  are  not  uncommon  and  occasionally 
a  day  or  two  after  the  change  from  a  breech  to  a  vertex  presentation 
the  fetus  is  again  found  presenting  by  the  breech.  The  corrected  presen- 
tation can  sometimes  be  maintained  by  an  abdominal  binder,  but 
occasionally  all  efforts  in  this  direction  fail  and  the  presentation  is  best 
left  as  a  breech. 

It  should  be  remembered  that  breech  presentations  are  much  juore 
common  in  early  than  in  late  pregnancy  and  that  many  breech  presen- 
tations are  spontaneously  changed  to  vertex  presentations  between  the 
eighth  month  and  term.  The  close  of  the  eighth  month  or  the  beginning 
of  the  ninth  is  the  best  time  to  attempt  the  change  of  a  breech  to  a  vertex 
presentation  by  external  version.  At  an  earlier  period  the  operation  is 
often  unnecessary  and  at  a  later  period,  owing  to  the  growth  of  the  fetus, 
it  is  often  more  difficult.  For  a  breech  delivery  a  table  is  preferable  to 
a  bed  and  it  is  advisable  to  have  an  assistant  to  administer  the  anesthetic 
and  to  assist  by  pressure  upon  the  fundus  during  the  latter  part  of  the 
delivery,  leaving  the  nurse  free  to  make  preparations  for  the  baby, 
arranging  hot  and  cold  tubs  for  resuscitation  if  needed,  etc.  If  a  table 
is  not  available  for  the  delivery  the  patient  during  the  second  stage  should 
lie  across  the  bed  with  hips  near  the  edge  and  whether  on  the  table  or 
bed  she  should  be  placed  in  the  lithotomy  position,  with  knees  supported 
with  leg  holders,  and  draped  as  for  a  forceps  delivery  (see  page  758). 

Since  the  birth  of  the  head  is  the  most  critical  period  of  a  breech  delivery 
it  naturally  follows  that  full  dilatation  of  the  cervix  is  desired,  hence 
care  should  be  taken  to  preserve  the  membranes  intact  if  possible  until 
this  result  is  accomplished.  Furthermore,  as  the  soft  breech  is  not 
as  good  a  dilator  as  the  hard  fetal  head  it  is  advisable  (except  in  cases 
of  frank  breech,  where  on  account  of  threatened  impaction  it  is  neces- 
sary to  bring  down  a  foot)  not  to  interfere  with  the  presenting  pelvic 
extremity  until  it  reaches  the  vulva,  lest  the  size  of  the  dilating  body  be 
reduced  and  the  dilatation  be  imperfect. 

The  delivery  of  a  complete  breech  consists  of  three  parts :  The  first 
is  from  the  birth  of  the  foot  to  the  birth  of  the  navel;  the  second  is 
from  the  birth  of  the  navel  to  the  birth  of  the  mouth;  the  third  is  from 
the  birth  of  the  mouth  to  the  complete  birth  of  the  head.  The  first  part 
should  be  very  slow;  the  second  should  be  rapid;  the  third  should  be 
rapid  or  slow,  according  to  the  condition  of  the  fetus. 

When  the  foot  appears,  usually  the  anterior,  it  is  gently  lifted  out  and 
covered  with  a  towel  wrung  out  in  hot  sterile  water.  The  hot,  wet  towel 
has  a  threefold  purpose.  It  keeps  the  fetal  extremity  warm,  thus  pre- 
venting the  attempt  at  respiration  which  the  shock  of  air  lower  than 


304  THE  MECHANISM  OF  LABOR 

bo(l\  temperature  tends  to  cause;  it  preserves  the  vitality  of  the  fetus, 
and  it  renders  the  extremity  covered  with  vernix  caseosa  less  slippery 
in  the  obstetrician's  grasp.  The  delivery  to  the  birth  of  the  navel  should 
be  as  slow  as  i)ossible,  in  order  that  the  cervix  may  be  fully  dilated  by 
the  body  of  the  fetus,  thus  lessening  the  danger  of  the  passage  of  the 
larger  head.  To  this  end  no  traction  should  be  made  on  the  leg.  The 
delivery  should  be  made  by  uterine  effort  alone.  The  leg,  however,  may 
be  raised  gently,  thus  guiding  the  hips  up  over  the  perineum.  Soon  the 
second  leg  and  hip  appear  and  slip  over  the  perineum.  The  assistant, 
as  the  delivery  proceeds,  should  carefully  follow  down  the  fundus,  press- 
ing it  gently  with  both  hands,  and  keeping  it  contracted  on  the  dimin- 
ishing fetal  body.  If  the  uterus  be  allowed  to  balloon  up,  the  arms  of 
the  fetus  may  become  extended,  thus  giving  rise  to  what  is  often  a  serious 
complication.  The  assistant  should  be  especially  careful  in  following 
down  the  fundus  after  the  birth  of  the  navel,  as  this  is  the  time  v.hen 
the  arms  are  more  likely  to  become  extended.  As  more  of  the  body 
appears,  it  should  be  wrapped  in  the  hot,  wet  towel.  Finally,  the  navel 
appears  and  the  first  part  of  the  delivery  is  over.  The  cord  should  be 
pulled  down  in  a  loop  to  prevent  undue  traction  on  it.  The  second 
part  of  the  delivery  should  be  as  rapid  as  possible.  Until  the  birth  of 
the  navel  the  fetus  is  getting  its  supply  of  oxygen  through  the  placenta. 
After  the  birth  of  the  navel,  however,  the  cord  is  almost  sure  to  be 
pressed  upon,  and  the  placenta  often  begins  to  separate  from  the  uterine 
wall.  Hence,  the  fetus  is  cut  off  from  its  supply  of  oxygen  and  will  die 
unless  delivered  quickly.  Five  minutes  is  about  the  limit  of  time  which 
can  elapse  from  the  birth  of  the  navel  to  the  birth  of  the  mouth  without 
the  loss  of  the  fetus.  Therefore  no  time  is  to  be  lost.  The  fetus,  covered 
with  the  hot,  wet  towel,  is  firmly  grasped  by  the  body  above  the  iliac 
crests,  and  traction  is  made  downward  until  the  shoulders  appear  at  the 
vulva.  Then  the  body  of  the  fetus  is  raised  and  the  posterior  arm,  if 
flexed,  appears  at  the  perineum.  This  may  drop  out  spontaneously. 
If  not,  two  fingers  of  the  obstetrician's  hand — right  if  the  back  is  to  the 
right,  left  if  the  back  is  to  the  left — are  passed  along  the  fetal  back  and. 
o\er  the  shoulder,  hooking  down  the  arm  by  the  elbow.  The  body  is 
now  dejiressed,  and  the  anterior  arm  may  be  born  spontaneously  or 
easily  extracted.  If  not,  the  body  of  the  fetus  is  rotated  so  that  the 
anterior  shoulder  becomes  posterior  or  nearly  so,  when  two  fingers  of 
the  oi)i)osite  hand  are  inserted  over  this  shoulder,  again  hooking  down 
the  elbow.  Thus  the  attempt  is  made  to  deliver  the  arm  posteriorly 
only,  the  reason  being  that  the  muscular  perineum  gives  and  admits 
the  fingers  easily,  while  the  bony  pubic  arch  does  not.  This  is  all 
the  more  important  if  the  arms  are  extended,  a  condition  always  pos- 
sible, and  described  later  (see  page  713),  when  the  whole  hand  must  be 
inserted  for  a  greater  distance  to  bring  the  arms  down.  This  is  only 
possible  j)osteriorly. 

With  the  birth  of  the  shoulders  and  arms  the  back  of  the  fetus  is  turned 
upward  to  bring  the  occiput  anterior.  This  is  most  important.  The 
head  readily  follows  the  body  unless  the  pelvis  is  deformed,  and  it  is 


MECHANISM  OF  BREECH  PRESENTATIONS 


305 


usually  the  obstetrician's  fault  if  the  body  is  supinated  and  the  head 
rotates  posteriorly  (see  also  page  299). 

The  safest  way  of  delivering  the  after-coming  head,  the  critical  and 
most  difficult  part  of  the  delivery,  is  by  the  Mauriceau-Smellie-Veit 
method  (see  Fig.  220),  so  called  because  all  three  men  described  it. 

The  righti  hand  is  passed  under  the  child's  abdomen  and  the  fingers 
are  inserted  into  the  mouth,  and  with  slight  traction  the  head  is  well 
flexed.  We  have  seen  previously  why  complete  flexion  is  so  important. 
The  body  of  the  fetus  straddles  the  right  forearm  of  the  obstetrician. 
The  fingers  of  the  left  hand  make  traction  on  the  shoulders  of  the  fetus, 
one  on  each  side  of  the  neck.  Traction  is  made  downward  until  the  head 
is  felt  to  slip  under  the  pubic  arch.  The  body  of  the  fetus  is  now  lifted 
up  onto  the  mother's  abdomen,  and  is  supported  by  the  left  hand  and 
arm.    This  brings  the  mouth  of  the  fetus  over  the  perineum.    The  right 


Fig.  220. — -Mauriceau-Smellie-Veit  method. 


hand  is  slipped  down  and  guards  the  perineum,  exactly  as  in  vertex 
deliveries.  The  second  part  of  the  delivery  is  now  over  and  the  fetus 
is  safe,  unless  the  delivery  has  been  too  long  or  difficult. 

The  head  is  delivered  over  the  perineum  exactly  as  in  a  vertex  case. 
There  need  be  no  hurry  if  the  fetus  is  in  good  condition,  as  it  will  begin 
to  breathe  and  even  to  cry  as  soon  as  the  mouth  is  born.  The  perineum 
can  be  gradually  distended  and  the  delivery  made  without  serious  tear- 
ing. Should  the  fetus  be  in  a  bad  condition,  this  part  of  the  delivery 
must  be  hurried  regardless  of  the  perineum.     Anesthesia  can  be  given 

1  The  right  hand  is  used  under  the  child's  abdomen,  as  this  is  the  hand  with  which  the 
perineum  is  guarded  in  vertex  deliveries,  and  the  hand  under  the  child  is  more  quickly- 
slipped  down  onto  the  perineum  than  the  hand  on  the  shoulders.  In  some  cases,  however, 
especially  in  flat  pelves,  the  head  comes  through  the  pelvis  transversely,  and  when  the  face 
is  found  to  be  markedly  turned  toward  the  mother's  right,  it  is  easier  to  use  the  left  hand 
under  the  abdomen  so  that  it  can  easily  reach  the  mouth.  In  Fig.  220  the  left  hand  is 
represented  under  the  abdomen. 
20 


300  THE  MECHANISM  OF  LABOR 

■iftor  the  l)irth  of  tlie  navel  if  the  patient  is  inclined  to  resist  and  to  be 
unrnly.    if  given  after  the  birth  of  the  mouth  it  tends  to  prevent  rupture 

of  the  perineum.  •  1 1     ^i 

The  placenta  follows  the  birth  of  the  child  more  quickly  than  ma 

vertex  delivery,  as  it  often  begins  to  separate  when  the  fetus  is  partly 

born,  as  was  mentioned.  ,     ,    . 

For  the  complications  of  breech  delivery  and  their  management  see 

page  711. 


CHAPTER  IX. 
THE  MANAGEMENT  OF  NORMAL  LABOR. 

MANAGEMENT    OF   THE   FIRST   STAGE. 

In  describing  the  management  of  a  case  of  labor  something  should  be 
said  about  the  summons.  The  two  disagreeable  features  in  the  practice 
of  obstetrics  are  the  uncertainty  of  the  summons  and  the  long  hours  of 
waiting.  I  have  spoken  of  the  summons  as  uncertain  and  I  would  have 
every  student  of  obstetrics  looking  forward  to  this  as  a  lifework  con- 
sider well  what  this  means.  The  call  to  an  obstetric  case  is  likely  to  come 
just  at  a  time  when  he  least  desires  it.  At  night,  perhaps  when  he  is 
all  tired  out  with  his  day's  work;  in  the  daytime,  when  he  has  filled 
every  hour  of  the  day  with  previous  engagements.  This  must  be  expected 
not  only  once,  but  frequently  in  the  life  of  the  obstetrician.  He  may  have 
to  give  up  a  large  part  or  the  whole  of  his  vacation  just  because  an 
obstetric  case  does  not  go  into  labor  at  the  time  expected.  These  and 
the  long  tedious  hours  of  inactivity,  waiting  at  the  house  of  the  patient 
for  nature  to  do  her  work,  are  the  disagreeable  features  in  the  practice  of 
obstetrics  and  yet  no  one  should  engage  in  this  line  of  work,  and  no  one 
deserves  success  in  it,  who  is  not  willing  to  give  an  obstetric  call  pre- 
eminence over  every  other  engagement,  who  is  not  willing  to  respond 
at  once  to  the  call  of  the  woman  who  has  entrusted  herself  to  his  care 
and  placed  her  full  confidence  in  him. 

It  has  always  seemed  to  the  author  that  the  fact  of  a  pregnant  woman 
placing  herself  and  her  unborn  child  unreservedly  in  the  care  of  an 
obstetrician  carried  with  it  greater  moral  obligation  on  the  part  of  the 
latter  to  be  loyal  to  her  in  every  way  than  did  any  other  engagement  in 
medicine. 

There  may  be  mentioned  another  disagreeable  feature  in  the  practice 
of  obstetrics,  and  that  is,  the  liability  to  criticism.  For  so  many  years 
has  labor  been  considered  a  normal  physiological  process  which,  with 
proper  care,  should  have  no  complications  for  mother  or  child,  that  there 
is  a  tendency  especially  among  women  and  their  friends  to  blame  the 
obstetrician  if  anything  unfavorable  occurs,  no  matter  how  unjust  this 
criticism  may  be. 

Thus  far  the  unfavorable  side  of  obstetrics  has  been  depicted  and  it  is 
well  to  look  at  this  side  carefully  before  selecting  it  as  a  specialty. 

There  is  another  side,  however,  and  in  the  judgment  of  the  author 
it  is  the  weightier. 

There  is  no  branch  of  medicine  in  which  the  doctor  comes  so  near  to 
the  heart  of  his  patient  as  does  the  obstetrician,  who  by  his  skill,  careful 

(307) 


308  THE  MANAGEMENT  OF  NORMAL  LABOR 

attention  and  sympathy  has  carried  a  woman  safely  through  wliat  is 
l)erhaps  the  most  trying  experience  of  her  Hfe.  He  has  safely  guarded 
her  confidences  early  in  pregnancy.  He  has  been  ready  with  kindly 
advice  to  lessen  as  far  as  possible  the  discomforts  of  the  later  months 
and  by  his  skill  and  sympathetic  encouragement  he  has  safely  guarded 
her  through  labor.  Is  it  any  wonder  that  the  conscientious,  skilled 
obstetrician  possesses  the  respect  and  affection  of  his  i)atients  to  a 
degree  which  enables  him  to  forget  the  discomforts  of  the  untimely  call, 
the  loss  of  sleep,  and  the  bodily  fatigue.  Another  pleasant  feature  of 
obstetrics  is  the  happy  atmosphere  of  the  home  of  the  new  arrival.  AYith 
the  suffering  and  anxiety  passed  and  the  baby  an  ever-increasing  joy 
in  the  household,  the  sunny  atmosphere  of  the  home  during  the  normal 
puerperium  makes  the  visits  of  the  obstetrician  a  pleasure. 

From  what  has  been  written  above  it  is  evident  that  the  obstetrician 
should  respond  at  once  to  the  needs  of  his  patient.  On  the  other  hand,  if 
he  has  seen  his  patient  frequently  during  pregnancy  and  has  assured 
himself  of  the  size  of  the  pelvis  and  the  presentation  and  position  of  the 
child,  and  furthermore,  if  at  the  home  of  his  patient  there  is  a  nurse  with 
whose  training  and  skill  he  is  familiar,  it  is  not  necessary  for  the  obstet- 
rician to  be  called,  or  to  visit  his  patient  during  the  early  part  of  the 
first  stage  of  labor. 

The  Nurse. — So  much  depends  upon  the  cleanliness,  the  skill  and  the 
personality  of  the  nurse  that  a  few  words  concerning  her  will  not  be  out 
of  place.  While  formerly  the  old  monthly  nurse  was  the  rule  and  the 
hospital-trained  nurse  the  exception,  with  the  increase  in  the  number 
of  training  schools  and  opportunities  for  nurses  to  become  trained  in 
obstetrics,  this  rule,  especially  in  the  higher  walks  of  life,  is  rapidly  coming 
to  be  reversed,  and  the  selection  of  a  trained  nurse  for  his  patient  becomes 
one  of  the  first  duties  of  the  obstetrician.  Of  the  three  important  features 
of  a  nurse,  i.  e.,  cleanliness,  skill  and  personality,  in  the  mind  of  the 
obstetrician  the  first  two  receive  chief  attention,  while  it  is  the  last, 
or  the  personality  of  the  nurse,  which  most  appeals  to  the  patient  and 
upon  which  much  depends.  Admitting  that  the  patient  is  irritable  and 
unreasonable,  admitting  that  nurse  No.  1  is  just  as  skilful  as  No.  2, 
it  must  be  remembered  that  the  nurse  and  patient  are  to  be  together 
most  of  the  time  for  four  or  five  weeks,  and  unless  the  i)ersonality  of 
the  nurse  is  agreeable  to  the  patient  some  other  nurse  had  better  be 
selected. 

A  skilful  nurse  who  is  liked  by  the  patient,  and  who  by  her  tact, 
encouragement  and  sympathy  can  enable  her  to  look  forward  to  her 
labor  without  apprehension  and  endure  it  cheerfully  and  bravely  when 
it  arrives,  is  certainly  a  blessing  to  the  lying-in  chamber. 

The  selection  of  the  nurse,  however,  should  be  left  to  the  obstetrician, 
and  she  should  be  one,  if  possible,  with  whose  training  he  is  familiar, 
who  has  worked  with  him  and  who  knows  his  methods.  The  comfort 
to  the  obstetrician  of  having  a  nurse  upon  whom  he  can  thoroughly 
rely,  both  for  calling  him  at  the  proper  time  in  the  progress  of  the  labor 
and  at  the  first  indication  of  impending  danger,  who  is  calm  in  emer- 


MANAGEMENT  OF   THE  FIRST  STAGE  309 

gencies  and  quick  in  i)reparation  to  meet  them,  can  only  be  fully  appre- 
ciated by  those  who  have  enjoyed  this  pri\'ilege  and  then  been  deprived 
of  it.  As  a  rule  the  nurse  should  be  at  the  home  of  the  patient  at  least  a 
week  prior  to  the  calculated  date  of  labor. 

Preparation  of  the  Rooms. — The  lying-in  chamber  should  be  large  and 
pleasant  with  plenty  of  sunlight  and  easy  to  ventilate.  It  is  a  distinct 
advantage  if  it  contains  an  open  fireplace.  All  unnecessary  articles  of 
furniture  and  draperies  should  be  removed  and  a  bare  floor  with  a  few 
rugs  is  preferable  to  a  carpet.  The  baby  should  not  be  kept  in  the  room 
with  the  mother,  but  should  have  as  a  nursery  a  room  adjoining.  The 
reason  for  this  is  obvious.  If  kept  in  the  same  room  the  mother  is  apt 
to  be  awakened  by  its  every  cry,  while  if  in  an  adjoining  room  it  can  be 
attended  to  by  the  nurse  without  disturbing  the  mother  and  can  be  more 
easily  trained  to  its  regular  hours  and  habits,  as  the  trained  nurse  will 
readily  recognize  for  which  of  its  cries  the  baby  should  be  taken  up 
and  which  should  be  disregarded. 

This  is  easily  done  in  an  adjoining  room,  while  it  might  be  difficult 
if  the  baby  was  in  the  same  room  with  the  mother.  With  good  modern 
plumbing  and  ventilated  traps  it  is  a  great  convenience  and  perfectly 
safe  to  have  a  bath-room  opening  out  of  either  the  mother's  room  or 
the  nursery. 

Of  course  the  above  conveniences  are  only  possible  in  the  homes  of  the 
well-to-do,  but  the  writer  believes  that  it  is  always  well  to  study  ideals 
and  then  approximate  them  as  closely  as  possible. 

The  Conduct  of  the  Obstetrician. — Many  text-books  give  minute 
directions  as  to  the  conduct  of  the  obstetrician  when  called  to  a  case  of 
labor,  even  suggesting  subjects  of  conversation.  It  seems  to  me  that  this 
can  be  summarized  in  a  very  few  words:  Act  the  part  of  a  gentleman. 
Your  patient  has  sent  for  you  for  a  definite  purpose,  i.  e.,  to  aid  her  in 
her  distress  and  she  does  not  care  to  discuss  politics  or  the  weather.  She 
is  anxious  to  know  if  her  labor  is  progressing  normally,  if  she  and  her 
child  are  all  right,  and  she  will  probably  ask  you  how  long  her  labor  will 
continue. 

To  this  last  question  an  evasive  answer  had  better  be  given,  but  after 
you  have  assiu-ed  yourself  that  mother  and  child  are  all  right  and  the 
labor  progressing  normally,  a  few  words  of  encouragement  and  reassur- 
ance as  to  her  condition  will  be  of  great  comfort  and  assistance. 

The  Preparation  of  the  Bed. — As  soon  as  the  patient  has  well  started 
in  labor  the  bed  should  be  prepared  for  the  delivery,  and  fortunate  it  is 
for  the  obstetrician  and  the  nurse  that  the  old-fashioned,  low,  double 
bed  is  rapidly  giving  place  to  the  higher,  individual  bed,  which  with  doctor 
on  one  side  and  nurse  on  the  other  allows  the  patient  to  be  cared  for 
with  much  greater  convenience  and  less  fatigue  to  the  back.  According 
to  the  author's  experience,  the  following  arrangement  of  the  bed  proves 
most  satisfactory: 

Final  Bed. — There  is  first  made  up  the  bed  as  it  is  desired  for  the  patient 
to  lie  on  after  the  completion  of  the  delivery,  called  the  final  bed,  /.  e., 
over  the  mattress,  often  covered  with  a  washable  mattress  cover,  is  spread 


310 


THE  MANAGEMENT  OF  NORMAL  LABOR 


a  freshly  laundered  sheet,  tightly  stretched  and  fokled  nnder  at  the 
corners  (see  Fig.  221). 

Across  this  is  i)laced  a  piece  of  rubber  sheeting,  1x1^  yards,  which  is 
to  come  under  the  hips  of  tiie  patient.  This  must  be  spread  smoothly 
and  its  ends  folded  under  the  mattress  so  as  to  avoid  all  wrinkles  for 
the  patient  to  lie  on.  Over  this  is  placed  a  freshly  laundered  draw- 
sheet  made  by  folding  a  sheet  lengthwise  twice.  This  covers  the  piece 
of  rubber  sheeting  and,  like  it,  is  to  have  its  ends  folded  smoothly  under 
the  mattress.  This  completes  the  final  bed.  0\'er  this  is  now  made 
up  the  temporary  or  Jahur  bed. 

The  Temporary  or  Labor  Bed. — A  piece  of  rubber  sheeting  1|  x2  yards, 
large  enough  to  co\er  most  of  the  final  bed,  is  spread  over  the  bed 
already  made,  smoothly  stretched,  tucked  tighth^  under  the  mattress  or 
pinned  at  the  corners  with  safety  pins.  Over  this  is  placed  a  freshly- 
laundered  sheet  also  smoothly  stretched.  Across  the  middle  of  the 
bed,  where  the  buttocks  of  the  patient  are  to  lie  is  placed  a  sterilized 


Fig.  221. — Bed  arranged  for  delivery. 


obstetric  pad  (30  inches  square)  made  of  some  absorbent  material 
covered  with  absorbent  gauze.  This  has  the  advantage  of  being  com- 
fortable for  the  patient,  sterile  and  capable  of  receiving  the  discharges 
of  the  parturient  canal  with  very  little  soiling  of  even  the  surround- 
ing temporary  bed.  The  limbs  of  the  patient  are  covered  with  sterile 
stocking-drawers  and  a  sterile  towel  placed  across  the  abdomen,  the 
night-dress  being  drawai  up  to  the  breasts. 

At  the  close  of  the  labor,  the  bed  pad,  containing  the  discharges  is 
folded  up  and  slipped  from  beneath  the  buttocks.  The  patient  is  then 
turned  on  her  side,  the  sheet  and  rubber  of  the  temporary  bed  are  loosened 
from  beneath  the  mattress  and  rolled  up  longitudinally,  soiled  side  in, 
as  far  as  possible.  This  exposes  about  half  of  the  final  bed  and  on  to 
this  the  patient  is  now  rolled,  and  the  soiled  temporary  bed  is  slipped  off, 
leaving  the  patient  lying  on  the  clean  final  bed,  having  been  subjected 
to  scarcely  any  exertion  and  without  any  lifting  on  the  part  of  the  obstet- 
rician or  nurse.     On  this  final  bed  and  under  the  hips  of  the  patient 


MANAGEMENT  OF   THE  FIRST  STAGE  311 

there  should  now  be  placed  a  fresh  sterilized  bed  pad.  Where  it  can  easily 
be  so  arranged,  it  is  often  desirable  to  deliver  the  patient  upon  another 
bed,  or  if  an  obstetric  operation  is  to  be  performed,  upon  a  table  and 
then  at  the  close  of  the  labor  to  move  her  back  to  her  own  clean  bed 
which  has  been  prepared  for  her. 

Preparation  of  the  Patient. — At  the  onset  of  labor  the  patient  should 
be  given  a  thorough  soapsuds  enema  and  the  lower  bowel  well  emptied. 
If  the  membranes  haVe  not  ruptured,  she  should  then  receive  a  full  warm 
bath  with  free  use  of  \a  clean  soap,  especially  about  the  mons  veneris  and 
inner  surfaces  of  the\thighs,  followed  by  a  thorough  rinsing  with  fresh 
water  free  from  soap.  For  this  bath  the  ordinary  bath  spoMje, should  .f,  , 
not  be  used,  but  a  freshly  laundered  wash  cloth.  Y^-M^mLs  )»<lfc«^«**»  ^sa^M^i 

If  the  membranes  have  ruptured,  in  order  to  avoid  the  possibility  of  ' 
infection  from  the  entrance  into  the  amniotic  sac  of  the  soiled  bath  water, 
attention  to  the  danger  of  which  has  been  called  by  Stroganoff,^  Sticher  and 
others,  the  tub-bath  is  omitted,  and  in  its  place  a  thorough  sponge  bath 
is  given  by  the  nurse.  The  nurse  should  then  clip  closely  with  the  scissors 
the  hair  of  the  \ailva,  or  shave  it  with  a  safety  razor.  In  his  service  at 
the  Sloane  Hospital  the  author  uses  a  safety  razor  for  this  purpose,  but 
in  his  private  practice  usually  employs  the  method  of  clipping  with 
scissors.  After  the  nurse  has  clipped  or  shaved  the  vulva  she  washes 
it  thoroughly  from  above  downward,  i.  e.,  from  mons  veneris  to  and 
beyond  the  anus  with  sterile  cotton  swabs  and  sterile  soap  and  water, 
including  in  this  cleansing  the  inner  surfaces  of  the  thighs  as  well.  She 
then  washes  these  parts  thoroughly  with  sterile  water  and  then  with  lysol 
solution  (0.5  per  cent.)  and  applies  a  sterile  vulva  pad;  it  being  desired 
to  keep  the  vulva  covered  with  a  sterile  dressing  during  the  labor. 

It  will  be  noticed  that  no  antepartum  douche  is  advised.  For  many 
years  it  has  been  my  custom,  both  in  hospital  and  in  private  practice,  to 
omit  all  antepartum  douching  for  three  reasons: 

1.  The  probability  of  interference  by  douching  with  nature's  safe- 
guards against  infection. 

2.  The  possibility  of  introducing  infection  from  without  into  a  prac- 
tically sterUe  vaginal  canal. 

3.  The  results  of  experience  showing  the  morbidity  and  mortality  of 
patients  as  low  without  douches  as  when  douches  are  given  and  perhaps 
lower. 

Of  1990  cases  observed  by  Bretschneider,^  1018  received  a  vaginal 
douche  and  972  were  not  douched.  The  number  of  those  showing  fever 
in  the  puerperium  was  higher  by  3.73  per  cent,  in  those  douched  than 
in  those  not  douched. 

It  is  my  custom  never  to  allow  a  nurse  to  make  a  vaginal  examination, 
as  I  prefer  to  take  all  responsibility  of  infection  through  examination. 
Nor  does  it  seem  to  me  necessary  that  a  nurse  should  thus  examine, 
for  with  a  careful  study  of  the  patient's  pains  and  inspection  of  the  effect 

1  Centralblatt  f.  Gyn.,  February  9,  and  March  2,  1901. 

2  Klinische  Versuche  iiber  den  Einfluss  der  Scheidenspiilungen  wahrend  der  Geburt  auf 
den  Wochenbettsverlauf,  Arch.  f.  Gyn.,  1901,  Ixiii,  453-471. 


312  THE   MANAGEMENT  OF  NORMAL  LABOR 

of  these  pains  upon  the  i)elvic  floor  she  is  siiffieiently  a])le  to  report  to 
the  ohstetrieian  the  i)rogress  of  the  labor. 

Preparation  of  the  Obstetrician. — At  the  present  (hiy  it  is  well  known 
that  the  secret  of  success  in  obstetrics  is  asepsis,  or  surgical  cleanliness 
on  the  part  of  the  obstetrican  on  the  one  hand,  and  non-interference 
\vith  nature's  methods  of  asepsis  on  the  other.  Personal  asepsis  on  the 
part  of  the  obstetrician  may  be  secured  in  several  different  w^ays,  but  the 
three  principles  which  govern  the  methods  most  generally  employed  are: 

1.  Thorough  scrubbing  of  the  hands  and  forearms  with  sterile  soap 
and  water. 

2.  Disinfection  of  the  hands  and  forearms. 

3.  Covering  the  clothing  with  a  sterile  gown,  and  the  hands  wn'th 
sterile  rubber  gloves. 

Hand  Scrubbing. — This  is  in  all  probability  the  most  important  step 
in  all  methods  of  securing  personal  asepsis  and  w-ith  this  is  included 
the  care  and  cleanliness  of  the  finger  nails.  The  obstetrician  should 
always  endeavor  to  keep  his  fingers  in  as  normal  a  condition  as  possible 
with  nails  short,  well  rounded  and  smooth  and  without  "hang  nails." 
The  method  of  cleansing  employed  by  the  author  is  as  follows: 

Using  a  sterile  scrubbing  brush,  not  too  harsh,  the  hands  and  forearms 
are  scrubbed  with  tincture  of  green  soap  and  running  water  for  about 
two  minutes,  especial  attention  being  paid  to  the  scrubbing  of  the  finger 
nails. 

With  a  lemon  stick  or  nail  cleaner  the  finger  nails  are  then  carefully 
cleansed,  care  being  taken  not  to  cause  injury  in  so  doing.  The  scrubbing 
is  then  continued  for  about  two  minutes  and  the  hands  and  forearms  are 
then  rinsed  in  plain  water.  They  are  next  washed  with  50  per  cent, 
alcohol  to  remove  all  traces  of  soap  and  the  loosened  epidermis  and  they 
are  then  immersed  for  about  a  minute  in  a  dish  of  bichloride  (1  to  1000) 
deep  enough  to  allow  immersion  to  the  elbow,  and  sterile  rubber  gloves 
are  applied.  The  gloves  may  be  sterilized  either  by  dry  heat  in  a  steam 
sterilizer  or  by  boiling  in  plain  w^ater.  In  the  former  case  the  hands 
must  be  dried  with  a  sterile  towel  and  dusted  with  sterile  talcum  powder 
before  the  gloves  are  put  on.  In  the  latter  case  the  gloves  may  be 
emptied  directly  from  the  boiler  into  the  dish  of  lysol  solution  or 
bichloride  solution  and  put  on  wet. 

In  private  practice  it  is  very  desirable  to  have  in  one's  obstetric  bag 
two  pairs  of  rubber  gloves  of  which  at  least  one  pair  is  dry  sterilized, 
ready  for  immediate  use  at  any  time. 

After  the  sterile  gloves  have  been  put  on  it  is  the  custom  of  the  author, 
both  in  his  service  at  the  Sloane  Hospital  aid  in  his  private  practice, 
to  immerse  the  gloved  hands  in  lysol  solution  0.5  per  cent.  This  serves 
not  only  as  an  additional  disinfection,  but  the  lysol  solution  makes  a 
most  admirable  lubricant  and  by  the  author  no  other  is  used  either  for 
hands  or  instruments. 

For  covering  the  clothing  of  the  obstetrician  some  sort  of  a  sterile 
gow^n  or  suit  is  necessary.  The  author's  preference  is  to  wear  a  thin, 
long  rubber  apron  and  over  this  to  put  on  a  long  sterile  gown  which  is 


MANAGEMENT  OF   THE  FIRST  STAGE  313 

carried  in  the  obstetric  bag,  sterilized  in  a  separated  sack  which  is  closed 
with  a  stitch. 

The  Examination  at  the  Bedside. — Before  making  a  vaginal  examina- 
tion, and  therefore  before  thorough  sterilization  of  the  hands,  the  obstet- 
rician may  make  the  external  abdominal  examination  and  obtain  such 
information  as  is  possible  from  this.  The  patient  should  be  lying  on  her 
back  with  night-dress  dra"«Ti  up  to  the  breasts  and  sheet  drawn  down  to 
the  mons  veneris. 

Following  the  method  of  abdominal  palpation  described  in  Chapter  V, 
the  presentation  and  position  of  the  child  are  made  out  and  also  the 
amount  of  engagement  of  the  presenting  part.  The  auscultation  of  the 
fetal  heart  is  next  in  order  and  this  should  be  done  carefully,  as  the  com- 
parison of  subsequent  auscultations  during  labor  with  this  made  at  the 
beguining  gives  valuable  information  as  to  the  condition  of  the  child 
and  whether  or  not  it  is  being  subjected  to  too  long  pressure.  The 
importance  of  careful  observation  of  the  fetal  heart  during  labor  has 
only  been  duly  recognized  in  recent  years,  and  the  author  would  lay 
stress  upon  the  value  of  this  procedure  in  determining  when  acceleration 
of  the  delivery  by  forceps  or  otherwise  is  indicated. 

The  fact  of  excessive  or  too-prolonged  pressure  is  usuaU}^  indicated 
by  a  fetal  heart  which  is  not  only  markedly  slowed  during  the  pains,  but 
remains  between  the  pains  far  below  its  normal  rate  as  determined  by 
the  examination  at  the  begimiing  of  labor.  Any  embarrassment  felt  by 
the  patient  at  the  thought  of  examination  is  usually  lessened  during  the 
abdominal  palpation,  especially  if  she  is  assured  during  the  steps  of  the 
examination  that  the  presentation  and  position  are  normal  and  the  con- 
dition of  the  child  is  good. 

In  this  way  the  patient  becomes  accustomed  to  the  obstetrician  and 
by  the  time  he  is  ready  for  the  vaginal  examination  it  gives  her  little 
mental  shock  and,  as  a  rule,  little  objection  is  made. 

The  Vaginal  Examination. — When  discussing  the  preparation  of  the 
obstetrician  (page  312)  it  was  stated  that  the  secret  of  success  in  modern 
obstetrics  lay  in  (1)  asepsis  on  the  part  of  the  obstetrician,  and  (2)  Non- 
interference wath  nature's  methods  of  asepsis.  Of  late  the  danger  asso- 
ciated with  the  vaginal  examination  has  become  well  recognized  and  it 
is  seen  to  depend  not  only  on  the  first  of  the  conditions  mentioned  above, 
but  also  on  the  second,  i.  e.,  non-interference  with  nature's  methods  of 
asepsis. 

Let  us  consider  for  a  moment  the  normal  conditions  of  the  parturient 
canal.  The  uterine  cavity  during  pregnancy  is  sterile,  this  fact  having 
been  established  by  Doderlein,  Gonner  and  others,  and  accepted  by  prac- 
tically all  authorities. 

The  vagina  normally  contains  large  niunbers  of  bacteria,  mostly  bacil- 
lary  in  character,  although  at  times  cocci  are  found,  but  according  to 
Kronig,  Menge  and  AYilliams,  with  the  exception  of  the  gonoccoccus, 
these  bacteria  are  normally  non-pathogenic.  Hence  the  vagina  of  the 
normal  pregnant  woman  may  be  considered  practically  sterile  at  the 
time  of  the  onset  of  labor.    The  rulvsi  on  the  other  hand  abounds  in 


314  THE  MANAGEMENT  OF  NORMAL  LABOR 

t)acteriii,  both  i)atliogenic  and  uon-patliogenic.  During  the  progress  of 
the  labor  tlie  course  of  all  discharges,  mucus,  liquor  amnii,  and  blood  is 
outward,  tending  to  flush  out  and  cleanse  the  ])arturient  canal.  At  the 
completion  of  the  labor  the  expulsion  of  the  child,  as  also  that  of  the 
placenta  and  blood,  still  further  tends  to  wipe  out  the  canal.  The  con- 
traction of  the  uterus  and  the  closure  of  the  uterine  vessels,  both  by  this 
muscular  contraction  and  by  the  formation  of  thrombi  in  their  open 
mouths,  tend  to  prevent  the  entrance  of  bacteria  into  the  general  cir- 
culation.   These  are  the  factors  in  nature's  prophylaxis  against  infection. 

Having  then  a  parturient  canal  practically  sterile  from  fundus  to  vulva, 
but  non-sterile  at  the  vulva,  the  dangers  of  a  vaginal  examination  are 
apparent.  With  the  large  raw  surface  of  the  uterine  cavity  and  frequent 
abrasions  and  lacerations  of  the  lower  canal  the  soil  for  inoculation  with 
pathogenic  organisms  is  certainly  present  and  it  may  readily  be  seen 
how  even  a  sterile  finger  or  douche  nozzle  can  carry  infection  from  the 
non-sterile  vulva  without  to  this  sterile  soil  within. 

Accepting  these  as  the  normal  conditions  of  a  woman  in  labor,  although 
there  are  certain  rare  cases  of  infection  which  with  our  present  knowledge 
we  are  able  to  explain  in  no  other  way  than  that  they  are  cases  of  auto- 
infection,  ?'.  e.,  caused  by  pathogenic  bacteria  within  the  woman;  it 
must  be  admitted  that  m  ordinary  cases  of  infection  the  obstetrician  is 
the  causative  factor,  either  with  dirty  fingers  or  dirty  instruments  infect- 
ing the  sterile  canal,  or  with  sterile  fingers  or  sterile  instruments  carrying 
infection  from  the  non-sterile  vulva  without  to  the  sterile  canal  wuthin. 
Realizing  from  the  above  the  dangers  of  a  vaginal  examination,  the 
importance  of  making  them  as  infrequently  as  possible,  consistent  with 
the  knowledge  needed  is  evident,  and  also  the  value  of  substituting  the 
abdominal  examination  for  the  vaginal  whenever  practicable. 

The  Frequency  of  Vaginal  Examinations. — In  the  conduct  of  an  ordinary 
normal  obstetric  case  at  least  two  vaginal  examinations  are  usually 
desirable,  one  as  soon  after  the  arrival  of  the  obstetrician  as  the  patient 
and  he  can  conveniently  be  prepared  for  it,  and  the  other  immediately 
after  the  rupture  of  the  membranes. 

At  the  first  of  these  examinations  the  condition  of  the  vagina  and 
pelvic  floor  is  determined,  whether  or  not  they  are  softening  and  dilating 
under  the  influence  of  the  labor;  the  condition  of  the  bladder  and  rectum, 
whether  or  not  either  is  distended ;  the  condition  of  the  cervix,  the  amount 
of  its  dilatation  and  dilatability,  and  the  presentation  and  position  of 
the  child.  These  last,  however,  should  usually  be  determined  by  abdom- 
inal palpation,  and  the  vaginal  examination  by  feeling  the  sutures  and 
fontanelles  in  a  vertex  presentation,  and  the  sacrum  and  genitals  in  a 
breech  presentation,  should  serve  only  as  a  verification  of  the  diagnosis 
made  by  external  examination. 

This  vaginal  examination  should  also  determine  the  amount  of  mold- 
ing of  the  presenting  part  and  whether  it  is  advancing  as  it  should  with 
each  pain. 

Lastly,  the  examiner  should  note  carefully  the  interior  of  the  pelvis 
and  determine  whether  the  diagnosis  of  sufficient  room  made  during  the 


MANAGEMENT  OF   THE  FIRST  STAGE  315 

pregnancy  is  correct.  Before  making  any  vaginal  examination  the  \iilva 
should  always  be  carefully  inspected  for  evidences  of  \-enereal  disease, 
so  that  both  the  physician  and  nurse  may  be  safe-guarded  against  infec- 
tion and  if  evidences  of  gonorrhea  are  present,  that  additional  precautions 
may  be  taken  in  the  care  of  the  baby's  eyes. 

The  value  of  the  second  examination  immediately  following  the  rup- 
ture of  the  membranes  lies  in  the  fact  that  occasionally  with  the  gush  of 
liquor  amnii,  especially  if  the  presenting  part  does  not  accurately  fit 
the  pelvis,  a  loop  of  cord  prolapses  and  the  prompt  detection  of  it  not 
only  makes  its  replacement  easier,  but  may  save  the  life  of  the  child. 
Furthermore,  an  examination  after  the  rupture  of  the  membranes  enables 
the  obstetrician  to  more  readily  verify  his  diagnosis  of  presentation  and 
position,  if  there  was  doubt  before. 

While  two  vaginal  exammations  are  the  average  number  needed  in 
the  conduct  of  a  normal  case  of  labor,  yet  marked  variations  naturally 
occur.  In  some  cases,  especially  in  multigravidae  the  membranes  have 
ruptured  and  the  presenting  part  has  descended  well  into  the  pelvis 
by  the  time  the  obstetrician  reaches  the  patient,  so  that  only  one  vaginal 
examination,  perhaps  not  even  that,  is  needed.  On  the  other  hand,  in 
many  cases  of  prolonged  labor,  extending  over  many  hours,  several  vagi- 
nal examinations  may  be  indicated  at  intervals  of  two  to  four  hours,  in 
order  to  determine  whether  it  is  safe  to  leave  the  case  to  the  unaided 
efforts  of  nature  or  resort  should  be  had  to  one  of  the  obstetrical  operations. 

The  chief  points  to  remember  are  these:  Vaginal  examinations  during 
labor  should  be  made  as  infrequently  as  possible  consistent  with  the 
knowledge  needed,  and  each  A'aginal  examination  should  be  made  with 
the  greatest  care  to  avoid  the  possibility  of  infection. 

The  Method  of  Making  the  Vaginal  Examination. — ^After  the  obstetrician 
has  finished  the  abdominal  palpation  of  the  patient,  the  nurse  should  be 
asked  to  prepare  her  for  the  vaginal  examination,  while  he  prepares  his 
hands  as  described  on  page  312.  Having  thoroughly  scrubbed  and  disin- 
fected his  hands  and  forearms  and  put  on  sterile  rubber  gloves,  he  is  now 
ready  for  the  examination.  In  the  meantime  the  nurse  has  been  prepar- 
ing the  patient,  who  lies  on  her  back  with  knees  flexed.  After  the  nurse 
has  disinfected  her  oami  hands  she  washes  the  vulva,  previously  clipped 
or  shaved,  with  sterile  soap  and  water,  using  sterile  cotton  for  this  pur- 
pose, and  always  washing  from  mons  toward  anus,  not  in  the  opposite 
direction.  She  then  bathes  the  ATdva  with  lysol  solution  0.5  per  cent.,  and 
drapes  the  patient  with  a  sterile  or  freshly  laundered  sheet,  as  is  shown 
in  Fig.  222.  This  is  sometimes  spoken  of  as  the  U-sheet,  although  the  U 
is  inverted.  We  now  come  to  the  most  important  precaution  in  making 
the  vaginal  examination.  Realizing  that  the  vagina  may  be  considered 
practically  sterile,  and  that  the  vulva  in  spite  of  thorough  efforts  at 
cleansing  and  disinfection  is  probably  often  not  sterile,  the  object  desired 
is  to  introduce  the  sterile  gloved  fingers  mto  the  vagina  without  touching 
the  vulva  with  them.  Otherwise,  no  matter  how  sterile  the  fingers  are, 
or  how  sterile  the  vagina  is,  pathogenic  bacteria  may  be  wiped  off  from 
the  vulva  and  carried  hv  the  fingers,  then  infected,  to  the  vagina  and 


316 


THE  MANAGEMENT  OF  NORMAL  LABOR 


Fia.  223. — Method  of  making  a  vaginal  examination. 


MANAGEMENT  OF   THE  FIRST  STAGE 


317 


nature's  efforts  to  prevent  infection  be  thwarted.  The  best  method  of 
conducting  this  examination  is  as  follows  (see  Fig.  223).  The  labia  are 
well  separated  with  the  fingers  of  one  hand,  so  that  the  vaginal  orifice 
is  exposed.  The  examining  fingers  of  the  other  hand  are  then  introduced 
directly  into  the  vagina  without  touchmg  the  labia.  It  is  the  custom 
of  the  writer  before  introducing  the  fingers  to  immerse  the  examining 
hand  in  lysol  solution,  0.5  per  cent.,  and  to  bathe  the  vulva  with  the  same 
solution;  this  serving  as  the  best  lubrication  with  which  he  is  familiar. 


Fig.  224. — Method  of  putting  on  first  glove. 

Much  stress  may  well  be  used  on  the  value  of  sterile  rubber  gloves  in 
the  conduct  of  a  case  of  labor,  especially  by  those  who  are  doing  general 
medical  and  surgical  work.  For  those  obliged,  for  example,  to  treat 
sore  throats,  ulcers  of  the  legs,  contagious  diseases,  or  pus  cases  of  any 
kind,  and  at  the  same  time  attend  women  in  confinement,  it  is  practically 
the  only  way  in  which  they  may  reasonably  hope  to  avoid  infection;  but 
in  the  use  of  rubber  gloves  several  points  should  be  borne  in  mmd. 
Although  the  gloves  fresh  from  the  boiler  or  sterilizer  are  sterile,  they 
are  easily  infected  either  by  the  hands  in  putting  on,  or  by  touching 
non-sterile  objects  after  they  are  on.  For  these  reasons  the  hands  should 
be  thoroughly  cleansed  and  disinfected   as  previously  described,  before 


318 


THE  MANAGEMENT  OF  NORMAL  LABOR 


starting  to  i)ut  on  the  gloves,  and  in  putting  on  the  gloves  care  should  be 
taken  not  to  touch  the  outside  of  the  glove  with  the  ungloved  hand. 
If  the  gloves  are  sterilizefl  dry,  this  can  usually  be  accomplished  by 
ha\ing  the  wrists  of  the  glove  turned  back  when  sterilized,  and  putting 
them  on  as  shown  in  Figs.  224  and  225,  not  allowing  the  bare  skin  to 
touch  the  outside  of  the  glove.  If  the  gloves  are  sterilized  by  boiling, 
they  may  be  emptied  into  the  antiseptic  solution  and  put  on  direct 


Fig.  225. — Method  of  putting  on  second  glove. 

therefrom.  This  is  facilitated  by  having  the  glove  filled  ^^•ith  the  solution 
before  inserting  the  hand. 

After  the  gloves  are  on,  one  should  be  so  trained  as  to  have  it  ".second 
nature"  to  avoid  touching  any  non-sterile  object,  and  if  h\  accident  any 
such  object  is  touched,  the  gIo^■ed  hand  .should  be  immediately  washed 
m  some  such  disinfecthig  solution  as  bichloride  .solution,  1  to  1000. 

The  Stay  of  the  Obstetrician  at  the  Patient's  House.— It  is  easily 
understood  that  the  busy  physician  cannot  remain  at  the  patient's  house 


MANAGEMENT  OF   THE  SECOND  STAGE  319 

from  the  beginning  to  the  completion  of  every  labor.  On  the  other  hand, 
it  is  only  fair  to  the  patient  that  she  should  be  visited  and  carefully 
examined  by  her  obstetrician  as  soon  as  her  labor  has  well  started  and 
that  he  should  remain  with  her  during  her  second  or  expulsive  stage  and 
for  at  least  an  hour  after  the  birth  of  the  child.  After  a  careful  examina- 
tion during  the  first  stage,  experience  will  usually  indicate  to  the  physician 
how  long  he  can  safely  be  absent,  engaged  m  other  work,  without  being 
needed  by  the  patient,  and  if  there  is  a  well-trained  nurse  in  attendance, 
and  especially  if  he  can  communicate  with  her  frequently  by  telephone, 
he  is  often  enabled,  during  the  first  stage  to  devote  several  hours  to  other 
work.  He  should  alwaj's  hold  himself  in  readiness,  however,  to  come  at 
once  to  the  patient's  house  on  the  call  of  the  nurse.  During  the  first 
stage  it  is  a  good  rule  not  to  encourage  the  patient  to  use  her  abdominal 
muscles  during  uterine  contractions  as  it  usually  does  little  good  and  by 
forcing  the  undilated  cervix  doTMiward  it  tends  to  loosen  the  fascial  sup- 
port of  the  anterior  vaginal  wall  and  favors  the  development  of  a  cysto- 
cele.  During  this  first  stage,  unless  it  begins  at  night,  the  patient  should 
be  encouraged  to  be  up  and  walking  about,  as  engagement  of  the  present- 
ing part  and  dilatation  of  the  cervix  are  favored  by  the  upright  position. 
She  should  not  be  allowed,  however,  to  become  overfatigued  by  excessive 
walking.  If  the  first  stage  begins  at  night,  the  patient,  after  the  examina- 
tion of  the  obstetrician,  should  be  advised  to  get  some  sleep  if  possible, 
so  as  to  save  her  strength  for  the  demands  of  the  morrow.  If  the  first 
stage  is  at  all  prolonged,  it  is  desirable  to  give  the  patient  at  intervals 
some  easily  digested  nourishment  like  chicken-broth  or  beef-tea,  or  she 
may  have  a  cup  of  coffee  and  some  toast,  or  a  cup  of  tea  if  she  chooses. 
Care  should  be  taken,  however,  to  select  only  such  food  as  will  not  inter- 
fere with  the  administration  of  the  anesthetic  during  the  second  stage. 
During  a  prolonged  first  stage,  if  the  patient  becomes  very  tired  and 
nervous  and  progress  seems  to  be  interrupted,  nothing  appears  to  be  so 
effectual  as  to  give  the  patient  some  rest  by  the  administration  of  a  nerve 
sedative  like  chloral  or  an  opiate.  This  will  be  mentioned  later  when 
discussmg  uterine  inertia. 


MANAGEMENT    OF    THE    SECOND    STAGE. 

Durmg  the  second  stage  the  patient  should  usually  be  in  bed  or  on  the 
delivery  table  and  as  the  time  for  delivery  approaches,  as  shoA^ii  by  the 
bulging  of  the  pelvic  floor  and  beginning  gaping  of  the  vulvar  orifice, 
she  and  the  obstetrician  should  be  prepared  for  the  delivery. 

Posture  of  the  Patient. — The  position  of  the  patient  during  delivery 
may  largely  be  left  to  the  choice  of  the  obstetrician.  In  the  tenements, 
where  the  beds  are  apt  to  be  dirty,  it  is  sometimes  desirable  to  have 
the  patient  in  the  lateral  position,  so  that  the  hips  may  lie  at  the  edge 
of  the  bed  and  the  field  of  operation  be  surrounded  by  the  sterile  towels 
and  coverings  brought  by  the  obstetrician  (see  Fig.  226),  thus  avoiding 
contact  with  the  bedding  found  in  the  room.    This,  moreover,  is  the  posi- 


/ 


320 


THE  MANAGEMENT  OF  NORMAL  LABOR 


tioii  preferred  in  England  and  in  many  places  on  the  Continent.  During 
the  early  years  of  the  writer's  practice  this  was  the  position  usually 
employed.  Many  years  ago,  however,  the  author  abandoned  it  for  the 
dorsal  position  and  for  the  following  reasons: 

It  is  difficult  to  keep  the  patient  quiet  in  the  position  desired  for  the 
lateral  posture.  One  wishes  the  knees  kept  flexed,  the  upper  knee  (the 
right)  a  little  more  flexed  than  the  lower.  During  her  pains,  however, 
the  patient  is  very  apt  to  extend  her  legs,  perhaps  throw  herself  about 
and  disarrange  the  sterile  coverings  with  which  the  obstetric  field  is 
surroimded.  ^Moreover,  for  the  auscultation  of  the  fetal  heart,  a  very 
important  feature  in  the  proper  conduct  of  a  labor,  it  is  usually  necessary 
to  turn  the  patient  on  to  her  back,  thus  changing  her  position  and  cover- 
ings. Furthermore,  it  is  much  more  difficiilt  to  follow  the  progress  of  the 
labor  by  abdominal  palpation  in  the  lateral  position  than  in  the  dorsal. 


Fig.  226. — Patient  in  lateral  position  on  Kelly  pad  with  limbs  covered  with  sterile 
stocking-drawers  and  field  of  operation  surrounded  by  four  sterile  towels.  Pud  and  drapery 
brought  by  obstetrician. 

For  these  reasons,  both  in  his  service  at  the  Sloane  Hospital  and  in 
his  private  practice,  the  dorsal  position  is  preferred  by  the  author  for 
normal  deliveries,  and  in  all  obstetrical  operations  the  dorsal  position  is 
almost  universally  employed. 

Draping  of  the  Patient. — As  the  second  stage  approaches  its  close  the 
patient  should  l)e  draped  for  her  delivery.  '  The  nurse  should  roll  up  the 
patient's  night-dress  and  undervest  well  under  the  breasts  to  prevent 
soiling.  A  pair  of  sterile  stocking-drawers  should  be  put  on,  and  the 
gap  between  the  night-dress  and  the  stocking-drawers  should  be  covered 
with  a  sterile  towel.  Under  the  patient's  hips  should  be  placed  a  sterile 
bed  pad,  already  described  (see  Fig.  227). 

Preparation  of  the  Obstetrician. — As  the  time  for  the  deli\ery  ap- 
proaches the  obstetrician  should  put  on  a  sterile  gown  and  after  a  fresh 
scrubbing  and  disinfection  of  his  hands  and  forearms  should  see  that  his 
rubber  gloves  are  sterile,  as  already  indicated. 


MANAGEMENT  OF  THE  SECOND  STAGE 


321 


Instructions  to  the  Patient. — The  second  stage  of  labor  is  usually 
greatly  facilitated  by  a  few  words  of  instruction  given  to  the  patient. 
She  should  be  told  to  avoid  crying  out  as  far  as  possible  and  encouraged 
to  draw  in  a  long  breath  as  a  pain  approaches,  then  to  hold  it  and  bear 
down  at  the  acme  of  each  contraction.  Lying  on  her  back  with  knees 
flexed,  she  can  grasp  each  side  of  the  mattress  or  the  head  of  the  bed, 
and  can  aid  her  uterine  and  abdominal  muscles  by  pulling  on  the  mattress 
or  pushing  on  the  head  of  the  bed,  or  in  place  of  this  she  can  pull  on  the 
hands  of  the  nurse  whose  position  is  on  the  opposite  side  of  the  bed  from 
the  obstetrician,  or  on  a  folded  sheet  attached  to  the  foot  of  the  bed. 
The  patient  should  be  told  not  to  touch  the  sterile  hands  of  the  obstet- 
rician, nor  the  sterile  towel  on  her  abdomen.  To  avoid  this,  in  hospital 
practice,  it  is  often  desirable  to  place  about  the  wrists  of  the  patient 
a  pair  of  padded  wrist  bands,  which  are  attached  to  the  table  with  mobility 
enough  to  allow  the  patient  to  grasp  the  sides  of  the  table,  if  she  wishes, 


Fig.  227. — Patient  draped  for  delivery  in  private  practice. 


but  without  sufficient  mobility  to  allow  her  to  touch  the  hands  of  the 
obstetrician  or  the  abdominal  towel.  During  the  second  stage  of  labor, 
especially  as  the  presenting  part  approaches  the  vulva,  the  suffering  of 
the  patient  should  be  relieved  and  voluntary  muscular  contraction  be 
controlled  by  the  use  of  an  anesthetic. 

Anesthesia  during  the  Second  Stage  of  Labor. — For  the  introduction 
of  the  use  of  anesthesia  to  relieve  the  suffering  of  women  in  labor  we  are 
indebted  to  Sir  James  Y.  Simpson,  the  discoverer  of  chloroform.  x4.1though 
ether  was  previously  employed  by  him  for  this  purpose,  he  substituted 
chloroform  for  it  soon  after  his  discovery  of  this  anesthetic^ 

Opinions  differ  among  different  obstetricians  and  in  different  localities 
as  to  the  choice  of  anesthetic  for  this  purpose,  some  even  going  to  the 
extreme  of  doubting  the  wisdom  of  allowing  any  anesthetic  during  labor 
unless  an  obstetrical  operation  is  to  be  performed.  The  author  firmly 
believes  that  the  suffering  of  a  woman  during  the  second  stage  of  labor 
21 


322  THE  MANAGEMENT  OF  NORMAL  LABOR 

should  be  relieved  by  anesthesia  and,  furthermore,  the  use  of  anesthesia 
enables  the  obstetrician  to  largely  control  the  advance  of  the  presenting 
part  at  the  vulvar  outlet  and  is  therefore  of  great  assistance  in  preserv- 
ing the  integrity  of  the  pelvic  floor.  The  choice  of  the  anesthetic,  how- 
ever, is  an  important  one  and  should  be  based  chiefly  upon  the  physical 
condition  of  the  woman.  As  is  shown  in  the  chapter  on  Toxemia  of 
Pregnancy  (see  page  435)  it  is  now  Avell  established  that  chloroform  may 
produce  lesions  in  the  liver  resembling  those  found  in  the  toxemia  of 
pregnancy,  with  or  without  eclampsia.  It  is  therefore  unjustifiable  in 
cases  suffering  with  the  toxemia  of  pregnancy  to  use  as  an  anesthetic 
that  which  would  tend  to  increase  the  pathological  lesions.  For  this 
reason  in  recent  years  the  author  has  made  it  a  rule  in  all  cases  of  toxemia 
to  employ  ether  rather  than  chloroform  in  the  second  stage  of  labor  and 
in  all  operations  needing  an  anesthetic.  The  question  is  naturally  asked: 
Why  not  use  ether  in  all  cases  of  labor,  rather  than  chloroform?  The 
autihor  in  his  service  at  the  Sloane  Hospital  tried  for  a  time  to  abandon 
the  use  of  chloroform  during  labor  and  to  employ  ether  as  a  substitute 
in  all  cases.  The  result  was  so  unsatisfactory  to  both  physicians  and 
nurses  that  he  was  obliged  to  return  to  the  use  of  chloroform  in  all  cases 
where  evidences  of  a  toxemia  were  absent. 

The  features  desired  in  anesthesia  during  the  second  stage  of  labor  are: 

1.  Safety. 

2.  Rapidity  in  action. 

3.  Rapidity  in  passing  off. 

4.  No  excitement  of  patient. 

5.  No  nausea. 

With  the  exception  of  the  first  there  can  be  no  question  but  that  all 
these  features  are  possessed  by  chloroform  in  a  much  higher  degree  than 
by  ether.  The  ease  with  which  the  intensity  of  the  suffering  is  lessened 
by  a  whiff  or  two  of  chloroform;  the  rapidity  with  which  the  patient 
passes  imder  its  influence  and  rapidly  emerges  from  it  in  time  to  use  her 
voluntary  muscles  at  the  request  of  the  obstetrician;  the  absence  of 
excitement  and  struggling  under  chloroform  as  compared  with  its  fre- 
quency under  ether;  the  absence  of  nausea  with  chloroform  while  ether 
frequently  protluces  it;  these  features  all  argue  in  favor  of  chloroform 
if  we  can  be  assured  of  its  safety. 

Regarding  the  safety  of  chloroform,  it  must  be  admitted  that  in  con- 
ditions of  toxemia  it  is  not  as  safe  as  ether.  In  normal  conditions  of  preg- 
nane}^, howe\'er,  with  liver  and  kidney's  healthy,  the  experience  of  the 
author  and  his  associates  at  the  Sloane  Hospital  in  30,000  deliveries  and 
during  many  years  of  private  practice  seems  to  indicate  that  the  use  of 
chloroform  during  the  second  stage  of  labor,  when  carefully  administered, 
a  few  whiffs  at  a  time  during  the  pains,  is  relatively  free  from  danger. 

It  is  freely  admitted  that  harm  may  be  done  by  too  much  anesthesia 
during  labor.  If  too  much  anesthetic  is  given  the  uterine  contractions 
may  be  lessened  in  duration  and  frequency,  and  if  it  is  continued  too 
long,  it  favors  uterine  inertia  with  its  attending  dangers — postpartimi 
hemorrhage  and  puerperal  infection.     Furthermore,  by  this  prolonged 


MANAGEMENT  OF  THE  SECOND  STAGE  323 

anesthesia  the  Hfe  of  the  child  may  be  endangered  or  even  lost.  The 
effect  upon  the  child  of  an  anesthetic  administered  to  the  mother  is 
easily  seen  in  the  condition  of  the  child  delivered  by  Cesarean  section. 
It  is  often  quite  deeply  anesthetized  or  asphyxiated  and  may  require 
quite  active  efforts  at  resuscitation  before  it  cries  and  breathes  well. 

In  the  author's  method  of  anesthesia  in  labor,  in  cases  free  from  toxemia, 
a  chloroform  dropping  bottle  and  Esmarch  inhaler  is  placed  in  the  hands 
of  the  nurse  who  is  to  use  them  only  under  his  direction.  The  use  of  the 
chloroform  is  postponed,  if  possible,  imtil  the  latter  half  of  the  second 
stage,  although  occasionally  the  nervous  condition  of  the  patient  is  such 
that  even  at  the  begimimg  of  the  second  stage,  without  anesthesia,  instead 
of  aiding  her  uterine  contractions  by  voluntary  action  of  her  abdominal 
muscles,  she  seems  to  inhibit  them  and  it  is  fomid  that  by  giving  a  whiff 
of  chloroform  with  each  pain  her  nervous  system  is  quieted;  she  is  willing 
and  able  to  use  her  abdominal  muscles,  and  her  progress  in  labor  is 
immensely  aided.  The  writer's  custom  is  to  have  the  nurse  drop  several 
drops  of  chloroform  on  the  inhaler  and  have  the  patient  inhale  it  after 
each  downward  pressure  with  the  abdominal  muscles;  having  her  under- 
stand that  if  she  cries  out  and  does  not  press  do\ATiward  she  caimot  have 
the  relief  of  the  chloroform.  In  this  way  she  soon  learns  to  make  the 
most  of  her  energies  during  her  pains  and  rests  between  them,  the  inhaler 
being  removed  as  soon  as  the  uterine  contraction  has  ceased. 

If  the  chloroform  seems  to  lessen  the  uterine  contractions  in  frequency 
or  force  the  nurse  is  told  to  withold  its  use  during  the  next  pain.  The 
patient  will  often  ask  if  her  pains  are  to  get  worse  and  worse,  and  it  is 
always  a  comfort  to  her  to  be  assured  that  as  the  end  approaches  she 
will  receive  more  and  more  anesthetic  and  that  she  will  not  know  when 
the  child  is  born. 

As  suggested  here,  when  the  head  begins  to  distend  the  vulvar  orifice 
more  and  more  anesthetic  is  given  with  each  pain  imtil  just  as  the  head 
passes  the  ^-ulva  the  patient  is  anesthetized  to  the  surgical  degree. 

With  the  birth  of  the  child  the  use  of  the  anesthetic  is  discontinued, 
unless  marked  lacerations  need  repair,  or  for  some  reason  the  whole  hand 
has  to  be  introduced  into  the  uterus^  as  for  the  removal  of  an  adherent 
placenta  or  blood-clots.  It  should  be  borne  in  mind  m  this  connection 
that  the  use  of  chloroform  is  not  attended  with  the  same  freedom  from 
danger  after  the  birth  of  the  child  as  during  the  labor. 

Spinal  Anesthesia. — For  a  time  it  was  hoped  that  the  subarachnoidal 
injection  of  cocaine  or  some  of  its  derivatives  would  prove  a  safe  and 
reliable  method  of  relieving  the  suffering  of  labor.  Later  experience  with 
it,  however,  has  sho-^-n  the  method  uncertain,  some  patients  not  being 
relieved  by  it,  and  in  some  relief  being  only  of  very  brief  duration.  ^lore- 
over,  the  after-effects  of  the  method  in  the  shape  of  headache  and  nausea 
are  usually  very  distressing,  and  what  is  of  more  importance,  in  a  series 
of  1708  cases  in  which  it  was  used,  as  reported  by  Halm.^  there  were 
eight  deaths  in  some  of  which  autopsy  showed  a  meningitis  due  to  infec- 

1  Ueber  subarachnoideal  cocaininjectioiien  nach  Bier.  Centralbl.  f.  d.  Grenzgebiete  der 
Med.  u.  Chirurgie,  1901,  iv,  304-317  und  340-354. 


324  THE  MANAGEMENT  OF  NORMAL  LABOR 

tion.  For  these  reasons  the  method  has  fallen  into  disuse  and  is  not  to 
be  recommended. 

Scopolamin-morphin ;  Scopolamin-narcophin  Anesthesia. — The  so-called 
"twilight  sleep,"  or  Dammerschlaf. 

During  the  past  year,  through  the  lay  press  of  America,  the  use  of 
a  combination  of  scopolamin  and  morphin,  or  narcophin,  to  produce 
a  lessening  and  forgetfulness  of  the  sufferings  of  childbirth,  has  been 
brought  into  great  prominence. 

That  a  combination  of  these  drugs  could  be  used  for  this  purpose  was 
first  brought  out  by  Steinbuchel  in  1902.  To  Kronig  and  Gauss,  of 
Freiburg,  belong  the  honor,  however,  of  developing  the  method  as  it 
is  kno'ttTi  today,  and  they  have  used  it  since  1906  at  the  Freiburg  Clinic. 
Gauss's  first  paper  on  the  subject  appeared  in  1906  and  contained  a  report 
of  500  cases  treated  with  these  drugs  without  injury  to  mother  or  child. 

According  to  Kronig  and  Gauss  the  objects  sought  at  the  Freiburg 
Clinic  are: 

1.  That  the  woman  shall  feel  the  pains  of  labor  to  a  far  lesser  degree 
than  normal. 

2.  That  she  shall  lose  the  memory  of  the  pains  and  the  incidents  of 
childbirth. 

The  anesthesia  is  best  produced  in  a  darkened,  quiet  room.  As  the 
patients  are  susceptible  to  sudden  light  or  noise,  at  Freiburg  they  are 
given  dark  glasses  and  their  ears  are  filled  with  cotton.  The  drugs  used 
are  scopolamin  stable  and  either  morphin  hydrochloride  or  narcophin, 
an  opiate  closely  related  to  morphin  but  containing  more  narcotin. 

The  author  in  his  experience  with  the  method  has  used  only  the  com- 
bination of  scopolamin  and  narcophin.  According  to  Gauss  the  first 
injection  should  consist  of  both  the  scopolamin  and  the  opiate  but  the 
subsequent  injections  should  be  only  of  scopolamin. 

The  scopolamin  is  put  up  commercially  in  ampoules  containing  1  c.c. 
=  0.0003  gm.  or  gr.  lyii-o-  The  narcophin  should  be  made  up  in  small 
quantities  of  a  3  per  cent,  solution  so  that  1  c.c.  =  0.03  gm.  =  gr.  ss.  If 
morphin  hj^drochloride  is  used,  a  solution  is  made  so  that  1  c.c.  =  0.01 
gm.  or  gr.  i. 

Technic. — ^The  first  injection  is  given  when  the  labor  pains  become 
regular  and  active,  i.  e.,  when  the  interval  between  uterine  contractions 
is  about  five  minutes. 

The  two  drugs  are  injected  intramuscularly,  usually  in  the  gluteal 
region  and  separately,  although  usually  through  one  insertion  of  the 
needle.  The  fetal  heart  should  be  carefully  listened  to  before  beginning 
the  anesthesia  and  every  fifteen  minutes  during  the  labor.  The  initial 
dose  of  narcophin  0.03  gm.  or  gr.  ss  is  injected  and  then  through  the  same 
needle,  without  removing  it,  1.5  c.c.  scopolamin  stable  =  0.00045  gm. 
or  gr.  y-j-g  is  injected.  The  second  dose  consists  of  scopolamin  0.5  c.c. 
=  0.00015  gm.  or  gr.  -:^^-^^.  The  narcophin  is  not  repeated.  This 
second  dose  is  generally  given  about  an  hour  after  the  first.  About  half 
an  hour  after  the  first  injection  the  patient  begins  to  feel  drowsy;  she 
easily  falls  asleep  between  the  pains;  the  face  flushes  and  the  pupils 


MANAGEMENT  OF  THE  SECOND  STAGE  325 

become  dilated.  The  patient  often  complains  at  this  early  stage  of  dry- 
ness of  the  mouth  and  may  be  given  water  freely. 

Half  an  hour  after  the  second  injection  the  "memory  test"  should  be 
applied,  and  according  to  Gauss,  this  test  is  the  criterion  of  the  dosage. 
The  patient  is  asked  how  many  injections  she  has  had,  or  if  she  remembers 
an  object  which  had  been  shown  her,  or  some  previous  event  in  the  labor, 
etc.  If  she  does  not  remember  the  object  or  the  event,  the  third  injection 
may  be  deferred  for  an  hour  or  an  hour  and  a  half  from  the  second. 
A  primigravida  requires  on  an  average  five  or  six  injections  and  the 
intervals  between  them  is  determined  by  the  memory  test. 

Maternal  Results. — In  about  SO  per  cent,  of  cases  the  women  do  not 
remember  what  happened  while  they  were  under  the  influence  of  the 
drug. 

In  about  90  per  cent,  their  suffering  is  very  greatly  relieved.  The  first 
stage  of  labor  is  made  more  comfortable  and  in  the  author's  experience 
has  seemed  shorter  than  normal. 

The  second  stage  is,  as  admitted  by  all  obstetricians  who  have  used 
the  method,  considerably  prolonged.  Some  women  are  greatly  excited 
by  the  drugs,  makmg  it  difficult  to  keep  the  patient  in  bed  and  the  sterile 
drapery  in  place.  The  need  for  forceps  delivery,  in  the  interest  of  the 
child  as  well  as  the  mother,  is  increased  by  the  use  of  the  drugs. 

The  w^omen  on  the  day  following  the  delivery  seem  less  exhausted  than 
those  with  whom  this  method  has  not  been  employed. 

Fetal  Results. — That  the  fetus  is  affected  by  the  drugs  is  shown  by  the 
fact  that  when  the  child  is  born  the  pupils  are  often  dilated  and  the  skin 
is  often  dry.  While  many  of  the  children  will  breathe  and  cry  sponta- 
neously, a  certain  number  will  be  born  asphyxiated  and  require  active 
efforts  at  resuscitation  and  a  certain  number  will  be  born  in  a  condition 
gives  a  cry,  then  the  respiration  slows  down  and  becomes  shallow.  The 
which  at  Freiburg  is  called  oligopnea.  The  child  takes  a  breath  or  perhaps 
heart  becomes  slow,  perhaps  30  or  40  to  the  minute,  and  the  child 
becomes  cyanotic.  After  a  minute  or  two  the  child  begins  to  breathe 
more  regularly  and  rapidly  and  the  action  of  the  heart  improves.  In 
a  few  moments,  in  the  majority  of  cases,  even  if  nothing  is  done  to  the 
child,  the  pulse  and  respiration  become  normal.  The  return  to  normal 
is  hastened  by  active  measures  of  resuscitation.  Unfortunately  in  a  few 
instances  either  as  a  result  of  the  action  of  the  drugs  upon  the  individual 
baby,  or  on  account  of  the  prolonged  pressure  of  the  second  stage,  the 
child  at  birth  is  without  pulse  or  respiration  and  all  efforts  at  resuscita- 
tion fail. 

Conclusions. — ^After  a  year's  experience  with  scopolamin-narcophin 
anesthesia  in  obstetrics  the  author  has  reached  the  following  conclu- 
sions : 

It  is  contra-indicated  in  cases  of  primary  uterine  inertia,  as  it  tends  to 
check  the  labor. 

It  is  of  little  value  in  very  short  labors,  as  there  is  insufficient  time  for 
the  drugs  to  act. 

It  is  inapplicable  as  a  routine  procedure  in  a  large  teaching  institution 


326  THE  MANAGEMENT  OF  NORMAL  LABOR 

with  an  active  maternity  service,  as  the  staff  requirements  are  too 
great.  It  is  also  not  suitable  as  a  method  for  the  general  practitioner 
in  a  private  house.  In  certain  selected  cases  in  a  hospital  there  are 
advantages  to  the  mother  in  having  the  suffering  and  mcidents  of  the 
labor  obliterated  from  her  memory. 

The  danger  to  the  mother  from  the  use  of  the  drugs  employed  in  the 
so-called  "twilight  sleep"  is  not  great. 

There  is  always  a  certain  amount  of  danger  to  the  child  and  for  this 
reason  the  fetal  heart  should  be  listened  to  every  fifteen  minutes  from  the 
first  injection  till  the  child  is  born.  This  means  that  the  obstetrician 
or  his  trained  assistant  must  be  in  constant  attendance  during  all  this 
time. 

The  use  of  pituitary  extract  to  stimulate,  in  the  second  stage,  uterine 
contractions  which  have  been  markedly  lessened  by  scopolamin  and  an 
opiate  has  associated  with  it  considerable  danger  to  the  child. 

That  the  advantages  of  the  method  in  the  majority  of  cases  are  suffi- 
cient to  counter-balance  the  disadvantages  the  author  has  been  unable 
to  convince  himself. 

Nitrous  Oxide-oxygen  Anesthesia. — Following  the  recent  satisfactory  use 
of  this  anesthesia  in  surgery  its  emplo\Taent  in  obstetrics  has  of  late 
been  considerable.  It  is  early  yet  to  formulate  conclusions,  but  the 
experience  of  different  obstetricians,  including  the  author,  has  been  such 
as  to  warrant  a  further  trial  of  it. 

Preservation  of  the  Pelvic  Floor. — Probably  the  most  frequent  injury 
resulting  from  childbirth  is  laceration  of  some  part  of  the  pelvic  floor, 
especially  the  perinemn,  and  the  importance  of  this  laceration  is  seen 
from  the  fact  that  nearly  every  gynecologist  has  found  the  operation  of 
perineorrhaphy  among  those  he  is  most  frequently  called  upon  to  do. 
Fortunately  for  the  patient  the  obstetrician  has  learned  the  importance 
of  detection  and  repair  of  this  mjury  immediately  following  the  labor,  with 
the  result  that  fewer  women  find  the  need  for  consulting  the  gynecologist 
for  obstetrical  injuries.  For  many  years  it  has  been  said  that  a  very  large 
part  of  g^iiecology  has  been  due  to  bad  obstetrics.  It  may  be  justly 
stated  to  the  credit  of  the  obstetrician  that  this  donation  to  gynecology 
is  steadily  growing  less.  ■Minor  grades  of  laceration  of  the  permeum 
and  vaginal  wall,  especially  about  the  fourchette,  are  of  very  common 
occurrence,  even  in  the  hands  of  good  practitioners,  and  the  obstetrician 
who  states  that  he  has  delivered  a  large  series  of  cases  without  a  tear 
either  stamps  himself  as  a  poor  observer  or  as  one  whose  veracity  needs 
attention. 

Tears  are  found  much  more  frequently  m  primiparse  than  in  multi- 
parse.  Schroeder  observed  them  in  34.5  per  cent,  of  his  primiparse  and 
9  per  cent,  of  his  mm^iparse;  Olshausen  in  21.1  per  cent,  of  his  primi- 
parae  and  4.7  per  cent,  of  his  multiparae.  But  these  figures  must  have 
referred  to  fairly  deep  tears,  as  small  tears  of  the  fourchette  and  vagmal 
wall  near  it  occur  m  a  much  larger  percentage  of  cases. 

There  is  a  timidity  on  the  part  of  some  practitioners  in  acknowledging 
that  a  laceration  of  the  perineum  has  occurred  for  fear  they  be  criticized 


MANAGEMENT  OF  THE  SECOND  STAGE  327 

by  the  patient  or  her  family,  and  on  account  of  this  timidity  there  has 
been  a  tendency  to  avoid  careful  inspection  of  the  pelvic  floor  for  lacera- 
tions, the  obstetrician  not  wishing  to  find  them.  Fortunately  for  the 
patient,  the  laity  are  becoming  acquainted  with  the  fact  that  lacerations 
of  the  pelvic  floor  will  occasionally  occur  in  the  hands  of  the  best  opera- 
tors and  are  becoming  more  inclined  to  blame  not  the  physician  in  whose 
hands  the  laceration  occurred,  was  detected  and  repaired,  but  the  one 
in  whose  hands  it  occurred  and  was  neglected.  The  only  course  which 
is  safe,  both  for  the  satisfaction  and  the  reputation  of  the  obstetrician, 
is  to  inspect  carefully  the  pelvic  floor  after  labor  and  make  such  repairs 
as  are  needed. 

While  these  small  tears  are  often  beyond  the  control  of  the  obstet- 
rician the  deep  tears  in  a  normal  labor  can  be  largely  prevented  and  the 
occurrence  of  a  laceration  of  the  perineum  through  the  sphincter  ani  in 
a  normal  labor  usually  means  either  carelessness  or  lack  of  skill. 

Etiology  of  Laceration  of  the  Perineum. — The  following  may  be 
considered  the  causes  of  laceration  of  the  perineum. 

1.  Too  rapid  expulsion  of  the  presenting  part. 

2.  Faulty  mechanism  of  labor. 

3.  Disproportion  between  presenting  part  and  vulvar  outlet. 

4.  Abnormal  pelvic  outlet. 

5.  Lack  of  elasticity  in  the  pelvic  floor. 

Too  Rapid  Expulsion. — This  is  probably  the  most  frequent  cause  of 
laceration,  the  head  under  the  influence  of  a  powerful  uterine  contrac- 
tion, supplemented  by  vigorous  action  of  the  abdominal  muscles,  being 
suddenly  expelled  from  the  vulva  before  it  has  had  time  to  stretch. 

Faulty  Mechanism. — In  the  normal  mechanism  of  labor  flexion  is 
maintained  imtil  the  occipital  protuberance  has  descended  well  under 
the  symphysis  so  that  the  posterior  extremity  of  the  suboccipital  diam- 
eters lies  under  the  pubic  arch  as  extension  occurs,  i.  e.,  in  such  a 
manner  that  the  suboccipitobregmatic  and  suboccipitofrontal  diameters 
are  thrown  across  the  vulvar  orifice. 

If  extension  occurs  too  early,  so  that  the  occipitobregmatic  and  occipito- 
frontal are  substituted  for  the  suboccipital  diameters,  the  perineum  is 
exposed  to  greater  tension  than  normal  and  laceration  is  favored.  It  is 
readily  seen  that  in  brow  and  face  cases  and  in  cases  of  persistent  posterior 
position  of  the  occiput  laceration  may  often  be  met  with. 

Disproportion. — Sometimes  it  is  necessary  to  deliver  a  very  large 
head  through  a  very  small  vulvar  orifice  in  a  primigravida,  or  through  a 
pelvis  so  small  that  a  difficult  forceps  delivery  is  necessary,  or  perhaps 
the  hand  has  to  be  introduced  through  an  undilated  vulva  and  a  version 
performed.  In  such  cases  a  perineal  laceration  is  not  unusual  and  is 
excusable. 

Abnormal  Outlet. — In  some  cases  a  long,  narrow  pubic  arch  or  an 
abnormal  inclination  of  the  pelvis  may  expose  the  perineum  to  abnormal 
tension  and  laceration  occur. 

Lack  of  Elasticity.— This  is  most  often  seen  in  elderly  primigravidse, 
but  occasionally  in  younger  women  the  perineum  is  very  rigid  and 


328  THE  MAXAOEMENT  OF  NORMAL  LABOR 

unyielding  and  after  stretching  to  a  certain  size  it  will  suddenly  tear  like 
paper  through  a  couiiiderable  portion  of  its  depth.  While  usually  these 
tears  begin  in  the  vaginal  wall  near  the  fourchette  or  in  the  fourchette 
itself  and  extend  downward  and  backward,  they  sometimes  begin  in  the 
skin  surface  of  the  perineum  and  extend  both  upward  and  downward. 

Prophylaxis. — In  considering  the  causes  of  laceration  of  the  perineum 
it  was  seen  that  of  the  five  causes  given  there  are,  at  the  time  of  the  labor 
only  two  which  are  under  the  control  of  the  obstetrician,  viz.: 
{a)  The  rapidity  of  expulsion. 
(6)  The  mechanism  of  flexion  and  extension. 

Prophylaxis  then  must  be  directed  along  these  lines. 

For  many  years  the  attempt  to  preserve  the  pelvic  floor  was  spoken 
of  as  support  of  the  perineum.    In  the  light  of  present  knowledge  we  do 


Fig.  228. — Caput  in  sight. 

not  support  the  perineum  but  direct  our  attention  to  controlling  the 
rapidity  of  advance  of  the  head;  keeping  the  head  flexed  until  the  occipi- 
tal protuberance  is  well  under  the  pubic  arch,  then  keeping  the  nape  of 
the  neck  well  up  against  the  pubic  arch  while  extension  gradually  takes 
place.  This  control  of  the  rapidity  of  advance  is  maintained  by  the 
use  of  anesthesia  on  the  one  hand  and  by  external  pressure  on  the  other. 
As  the  caput  appears  in  sight  (see  Fig.  228j  the  patient  is  given  more 
anesthetic  during  her  pains  and  as  soon  as  her  voluntary  pressure  is  no 
longer  needed  she  is  told  to  breathe  rapidly  with  mouth  open  during  her 
pains  and  not  to  press  down;  at  the  same  time  the  anesthesia  is  deepened 
as  desired.  The  obstetrician,  standing  at  the  patient's  right,  with  his 
right  arm  under  her  flexed  thigh  and  gloved  hand  covered  with  a  sterile 
towel  to  protect  it  from  the  rectum,  surrounds  the  vulvar  orifice  with  his 
thumb  and  index-finger  (see  Fig.  229),  while  his  ring  and  other  fingers. 


MANAGEMENT  OF  THE  SECOND  STAGE 


329 


placed  behind  the  anus,  enable  him  to  control  very  largely  the  rapidity 
of  the  head's  advance.  This  control  is  rendered  more  complete  by 
pressure  with  the  index  and  middle  fingers  of  the  other  hand  directly 
on  the  fetal  head  showing  at  vulvar  orifice.  As  soon  as  possible  it  is 
desired  to  control  the  extension  of  the  fetal  head.  Up  to  this  point  the 
head  has  been  advancing  with  each  pain  and  receding  in  the  intervals. 
As  soon  as  the  occipital  protuberance  has  descended  well  beneath  the 
pubic  arch  the  head  can  be  held  in  the  position  desired  first  by  pressure 


Fig.  229. — Head  under  control.  Patient  deeply  anesthetized  for  a  few  moments.  The 
towel  in  the  photograph  has  been  allowed  to  slip  back  to  show  the  position  of  the  anus. 
In  practice  the  lower  gloved  hand  should  be  covered  with  a  sterile  towel. 

with  the  right  middle  finger  through  the  pelvic  floor  just  beneath  the 
forehead,  then  a  little  later  just  beneath  the  chin  of  the  child.  The 
patient  may  now  be  completely  anesthetized  as  the  farther  advance  and 
extension  of  the  head  are  entirely  within  the  control  of  the  obstetrician. 
When  the  vulvar  orifice  has  been  sufficiently  dilated  he  can  easily  shell 
out  the  head  in  an  interval  between  pains.  In  these  efforts  to  preserve 
the  perineum  and  deliver  the  head  many  operators  formerly  recom- 
mended the  introduction  of  the  finger  into  the  rectum.  This  should  be 
discountenanced  as  accompanied  by  danger  of  infection  both  to  mother 


330  THE  MANAGEMENT  OF  NORMAL  LABOR 

and  child  tJirougli  the  obstetrician's  finger.  While  it  is  desirable  to  have 
the  vulvar  orifice  sufficiently  dilated  to  allow  of  the  birth  without  lacera- 
tion, careful  observation  of  women  subsequent  to  their  confinement  have 
convinced  the  author  that  it  is  possible  to  restrain  the  advance  of  the 
head  too.  long  and  allow  of  too  much  stretching  of  the  vulvar  outlet; 
the  tissue  in  some  women  being  so  stretched  and  relaxed  that  it  does 
not  regain  its  tone.  In  many  cases  it  has  seemed  that  it  would  have  been 
wiser  to  allow  the  perineum  to  tear  and  then  repair  it,  rather  than  to 
allow  it  to  become  thus  overstretched.  Attention  may  also  be  called 
to  the  fact  that  if  the  umbilical  cord  is  coiled  about  the  neck  or  otherwise 
compressed,  too  long  detention  of  the  head  at  the  vulvar  outlet  may 
result  in  the  loss  of  the  child.  The  danger  can  only  be  foreseen  and 
averted  by  careful  observation  of  the  fetal  heart  sounds  and  the  early 
detection  of  their  irregularity. 

Episiotomy, — Some  obstetricians  believe  it  is  possible  to  tell  when  the 
perineum  is  to  tear  badly  and  prefer  to  cut  the  vulvar  outlet  with  knife 
or  scissors  in  an  oblique  direction  downward  and  backward  on  either 
side,  between  the  anus  and  the  tuber  ischii,  feeling  that  if  the  tension  is 
removed  there  will  be  no  tear,  or  if  it  does  occur,  the  tear  will  be  only  a 
continuation  of  the  incision,  and  will  heal  more  readily  than  the  irregular 
tears  without  incision.  The  author's  experience  leads  him  to  advise 
against  this,  as  in  the  first  place  it  seems  impossible  to  foretell  that  an 
extensive  tear  is  to  occur,  and  secondly,  properly  repaired  tears  usually 
heal  w^ithout  difficulty. 

Cord  about  the  Child's  Neck. — As  soon  as  the  head  is  born  the  adminis- 
tration of  the  anesthetic  should  cease.  The  finger  of  the  obstetrician 
should  be  passed  to  the  neck  of  the  child  to  ascertain  if  the  umbilical 
cord  is  coiled  about  it,  and  should  such  be  found  to  be  the  case,  the  cord 
should  be  loosened  and  slipped  over  the  head  of  the  child,  or  should  this 
not  be  possible,  it  may  be  loosened  so  that  the  child  can  be  born  through 
the  loop,  or  if  the  cord  is  too  tightly  coiled  to  allow  of  loosening,  it 
should  be  tied  or  clamped  twice  and  cut  between  the  ligatures  or  clamps. 
The  next  step  is  the  birth  of  the  shoulders. 

Delivery  of  the  Shoulders.  —  After  the  birth  of  the  head  there  is 
usually  a  few  moments'  delay  before  the  expulsion  of  the  shoulders 
and  trunk,  but  if  the  finger  has  determined  that  the  cord  is  not  coiled 
about  the  neck  and  the  fetal  circulation  appears  normal  this  slight 
delay  is  of  little  consequence  and  the  next  pain  usually  expels  the 
trunk.  The  lack  of  danger  in  slight  delay  under  these  conditions  may 
well  be  mentioned,  lest  the  cyanotic  condition  of  the  child's  face  lead 
to  too  rapid  and  forcible  interference.  If  the  head  of  the  child 
is  supported  by  the  hand  of  the  obstetrician  there  is  a  tendency  for 
the  posterior  shoulder  to  be  born  first,  as  claimed  by  Lefour,  Auvard, 
Leonet,  Edgar  and  others,  while  if  the  head  is  not  supported  the  anterior 
shoulder  tends  to  be  born  first.  It  is  the  author's  custom,  both  in  his 
service  at  the  Sloane  Hospital  and  in  his  private  practice,  to  favor  the 
birth  of  the  anterior  shoulder  first  (see  Fig.  230)  by  retarding  the  advance 
of  the  posterior  shoulder  and  by  lowering  the  hand  which  supports  the 


MANAGEMENT  OF  THE  SECOND  STAGE 


331 


head  and  for  the  following  reasons:  It  is  well  known  that  a  laceration 
of  the  perineum  which  was  only  very  slight  during  the  birth  of  the  head 
not  infrequently  becomes  plowed  out  into  an  extensive  laceration  by 
the  posterior  shoulder.  It  therefore  seems  reasonable  that  as  long  as 
slight  tears  in  the  perinemn  often  occur  during  the  birth  of  the  head 
extensive  tears  will  be  lessened  in  frequency  by  keeping  the  weight  of  the 
posterior  shoulder  off  the  perineum  as  much  as  possible  during  its 
birth.  If  the  posterior  shoulder  is  delivered  first  the  weight  of  the 
trunk  has  to  be  allowed  to  fall  upon  the  perineum  in  order  to  allow  the 
anterior  shoulder  to  be  disengaged  from  behind  the  symphysis  and 
emere-e  beneath  it. 


Fig.  230. — Birth  of  anterior  shoulder. 


If  the  anterior  shoulder  is  delivered  first  the  whole  weight  of  the  head 
and  trunk  can  be  raised  and  kept  off  the  perineum  as  the  posterior  shoul- 
der sweeps  over  it  (see  Fig.  231).  In  this  way  there  is  avoided,  as  far  as 
possible,  the  tendency  of  the  posterior  shoulder  to  increase  by  tension 
any  lacerations  which  have  occurred  during  the  birth  of  the  head. 

As  said  above,  the  birth  of  the  shoulders  usually  follows  soon  upon  the 
birth  of  the  head  and  without  difficulty,  especially  if  uterine  contraction 
is  supplemented  by  pressure  upon  the  fundus  by  either  nurse  or  assis- 
tant. Occasionally,  however,  there  is  delay  in  the  descent  of  the  shoulders 
and  the  condition  of  the  child  demands  that  the  birth  of  the  shoulders  be 
expedited.  This  can  usually  be  accomplished  by  seizing  the  sides  of  the 
child's  head  between  the  two  hands,  as  the  obstetrician  stands  at  the 


332 


THE  MANAOEMEXT  OF  NORMAL  LABOR 


right  of  the  patient,  and  drawing  shghtly  downward  and  outward  on  the 
head.  It  is  sometimes  necessary,  however,  to  insert  the  finger  into  the 
anterior  axilla  and  secure  the  delivery  by  traction. 

It  is  necessary  to  call  attention  to  the  fact  that  forcible  lateral  traction 
on  the  head  away  from  the  shoulder,  as  when  the  advance  of  the  shoulder 
is  obstructed,  is  not  devoid  of  danger,  as  it  occasionally  leads  to  such 
stretchmg  or  laceration  of  the  brachial  plexus  as  to  result  m  paralysis, 
called  the  birth  palsy  of  Duchenne  or  Erb's  paralysis. 

This  paralysis  may  also  be  produced  by  traction  upon  the  shoulders 
with  fingers  over  the  clavicles  in  delivering  the  after-coming  head.  The 
lesion  usually  involves  the  fifth  and  sixth  cervical  nerves  and,  although 


Fig.  231. — Birth  of  posterior  shoulder. 


the  nerves  are  only  slightly  injiu-ed,  spontaneous  recovery  may  occur 
within  a  few  weeks;  if  the  fibers  are  badly  torn  the  paralysis  may  be 
permanent  and  only  be  prevented  by  nerve  suture. 

As  the  trunk  rapidly  follows  the  birth  of  the  shoulders,  the  nurse  with 
her  hand  on  the  fundus  of  the  uterus  should  gently  follow  it  in  its  descent 
toward  the  pelvis.  Holding  the  top  of  the  fundus  in  the  palm  of  her 
hand  she  shoidd  gently  manipulate  it  mitil  she  is  certain  of  its  feel  and 
then  her  function  should  be  to  guard  the  fundus,  being  prepared  to 
knead  it  firmly -if  any  marked  hemorrhage  occurs,  but  otherwise  to  use 
only  sufficient  pressure  and  friction  to  ensure  against  ballooning  of  the 
uterus  with  blood,  but  not  enough  to  cause  marked  discomfort  to  the 


MANAGEMENT  OF  THE  SECOND  STAGE  333 

patient.    Leaving  the  contraction  of  the  uterus  to  the  guardianship  of 
the  nurse,  the  obstetrician  can  turn  his  attention  to  the  baby. 

Care  of  the  Child. — If  the  labor  has  been  normal  and  not  unduly  pro- 
longed the  child  will  usually  begin  to  cry  almost  immediately  after  its 
birth,  its  palor  or  cyanosis  then  changing  to  a  ruddy  pink  hue.  This 
inspiration  and  cry  can  often  be  stimulated  by  snapping  a  few  drops  of 
cold  boric  acid  solution  upon  it  as  the  eyes  are  washed  or  even  by 
blowing  upon  it.  If  it  does  not  begin  to  breathe  within  a  short  time  the 
cord  should  be  ligated  and  efforts  at  resuscitation  instituted  promptly. 
If  the  child  behaves  normally  it  is  laid  between  the  mother's  thighs 
near  enough  to  the  mother  to  avoid  traction  on  the  cord  and  the  eyes 
washed  with  boric  acid  solution  from  inner  to  outer  canthus.  The 
object  of  this  direction  is  to  avoid  infection  of  the  lachrymal  ducts.  The 
question  then  arises.  Shall  the  cord  be  ligated  at  once?  This  varies  with 
the  circiunstances. 

(a)  If  the  child  does  not  breathe  promptly,  as  indicated  above,  the 
cord  should  be  ligated  and  cut  at  once  and  efforts  at  resuscitation  insti- 
tuted. It  is  wise  under  these  circmnstances  to  ligate  the  cord  at  quite 
a  little  distance  from  the  child  so  that  after  the  tubbing  of  it  or  other 
manipulations  intended  to  stimulate  respiration,  the  cord  can  be  ligated 
and  cut  again  at  the  usual  distance  from  the  body  and  thus  the  stump 
of  the  cord  which  is  to  receive  the  sterile  dressing  be  saved  as  much 
as  possible  from  the  danger  of  infection  from  the  tub  or  manipulations 
of  artificial  respiration. 

(b)  If  the  child  is  vigorous  and  breathes  well  immediately  after  birth 
there  is  no  great  advantage  in  delaying  the  ligation  of  the  cord,  and  this 
is  usually  done  as  soon  as  the  eyes  have  been  washed  with  the  boric  acid 
solution. 

(c)  If  the  child  breathes  well  but  is  feeble  and  under  weight  there  are 
certain  advantages  in  waiting  until  the  pulsations  in  the  cord  have  nearly 
ceased  before  ligating  it.  It  is  estimated  that  the  child  gains  from  one 
to  three  ounces  of  blood  by  this  delay  of  a  few  moments  in  the  ligation 
of  the  cord.  The  increase  of  blood  to  the  child  is,  of  course,  fetal  blood 
which  has  been  forced  into  the  placenta  by  the  fetal  heart.  It  is  regained 
during  this  delay  in  two  ways: 

1.  By  thoracic  aspiration  produced  by  the  respiration  and  crying  of 
the  child  under  the  stimulation  of  the  atmosphere  which  is  lower  in  tem- 
perature than  the  liquor  amnii  with  which  it  was  previously  surrounded. 

2.  By  placental  compression  under  uterine  contraction  which  forces 
blood  from  the  placenta  along  the  umbilical  vein  to  the  fetus. 

The  gain  of  blood  to  a  feeble  child  is  often  of  considerable  importance, 
while  with  a  vigorous  child  it  would  be  of  little  moment. 

Method  of  Ligation  and  Dressing  of  the  Cord. — One  of  the  greatest  dangers 
to  which  the  newborn  child  is  exposed  is  infection  of  the  navel. 

In  order  to  avoid  this  the  greatest  care  should  be  observed  in  the 
treatment  of  the  umbilical  cord  and  its  stump  until  the  cord  is  off  and 
the  navel  thoroughly  healed.  A  few  principles  should  guide  us.  As 
it  is  an  established  fact  that  the  drier  the  stump  of  the  umbilical  cord 


334 


THE  MANAGEMENT  OF  NORMAL  LABOR 


can  be  kept,  the  sooner  the  cord  separates  and  the  navel  heals,  it  is  only 
rational  to  ligate  the  cord  at  no  great  distance  from  the  child's  abdomen 
and  to  have  as  little  fluid  as  possible  in  the  stump.  On  the  other  hand, 
it  occasionally  happens  that  either  on  account  of  the  first  ligature  cutting 
through  or  for  some  other  reason  it  is  necessary  to  apply  another  liga- 
ture between  the  first  ligature  and  the  child's  navel.  This  necessitates 
the  selection  of  the  site  of  the  first  ligature  at  a  sufficient  distance  from 
the  child's  abdomen  to  allow  of  the  application  of  another  ligature  proxi- 


Fig.  232.— First  knot. 


Fig.  23.3.— Second  knot. 


Fig.  234.— Third  knot. 


Fig.  2.35. — Fourth  knot. 


mal  to  it  if  necessary.  A  point  one  inch  from  the  child's  abdomen  will 
be  sufficient  for  this  purpose.  In  order  to  have  this  stump  as  small  and 
dry  as  possible  the  blood  and  Wharton's  jelly  of  this  portion  of  the  cord 
is  gently  stripped  toward  the  placenta  before  the  ligature  is  placed. 

Before  the  cord  is  cut  a  second  ligature  is  always  appliefl  on  the  placen- 
tal side  of  the  point  where  the  cut  is  to  be  made  for  the  following  reasons: 

1 .  The  possibility  of  a  twin  pregnancy  and  a  vascular  communication 
between  the  two  placentte  must  not  be  lost  sight  of,  although  the  latter 
is  rare. 


MANAGEMENT  OF  THE  SECOND  STAGE  335 

2.  The  retention  of  the  blood  in  the  placenta  keeps  it  a  firmer  object 
for  the  litems  to  act  upon  and  more  easily  expel. 

3.  It  prevents  the  soiling  of  the  bed  or  pad  upon  which  the  woman 
is  delivered. 

Attention  should  be  called  to  the  fact  that  the  blood  which  would 
flow  from  the  distal  end  of  the  cord  if  unligated  would  not  be  maternal 
blood,  but  fetal  blood  forced  into  the  placenta  by  the  fetal  heart.  This 
distal  ligature  is  usually  placed  from  1|  to  2  inches  from  the  first  and 
the  cord  cut  with  sterile  scissors,  not  too  sharp,  about  |  inch  from  the 
proximal  ligature. 

The  ligation  and  the  cutting  of  the  cord  should  be  done  with  sterile 
hands.  The  tape,  instruments  and  baby  shoidd  not  be  touched  by  any- 
thing non-sterile  until  after  the  cord  dressing  has  been  applied.  At 
the  Sloane  Hospital  the  following  method  of  ligating  the  cord  is  followed 
(see  Figs.  232,  233,  234,  and  235).  In  applying  the  first  ligature  the  tape 
after  the  first  double  knot  is  left  with  the  ends  long.  After  the  cutting 
of  the  cord  the  two  ends  are  tied  across  the  end  of  the  umbilical  stump, 
so  as  to  include  one  of  the  umbilical  arteries,  they  are  then  brought 
around  the  remainder  of  the  stump  and  tied  in  the  original  groove,  thus 
including  the  other  umbilical  artery.  Finally,  they  are  brought  once 
more  around  the  stump  as  a  whole  and  tied  in  a  double  knot.  This 
method  of  ligature  has  the  advantage  of  ligating  the  arteries  individually 
as  well  as  collectively  and,  furthermore,  tends  to  care  in  the  ligature  and 
watchfulness  to  prevent  oozing  or  secondary  bleeding. 

After  the  ligating  and  cutting  of  the  cord  the  baby  is  anointed  from 
head  to  feet  with  some  sterile  oily  substance  like  sterilized  petrolatum, 
or  albolene  to  remove  the  vernix  caseosa.  This  is  done  with  sterile  hands 
and  the  baby  is  then  wiped  clean  with  a  sterile  towel.  The  baby  is  not 
bathed  for  six  hours  after  birth  and  is  not  put  in  the  tub  until  the  cord 
is  off.  In  an  endeavor  to  find  a  method  which  would  keep  the  cord  dry 
and  sterile  and  favor  its  rapid  separation,  the  author  tried  in  different 
series  of  cases  a  variety  of  cord  dressings,  gauze  and  cotton  alone  and 
also  with  a  variety  of  different  powders;  talcum,  starch,  bismuth,  starch 
and  salicylic  acid,  boric  acid,  etc.  He  reached  the  conclusion  that  sterile 
gauze  was  better  than  cotton,  and  that  better  results  were  obtained 
without  rather  than  with  the  use  of  powders.  For  several  years  the  dress- 
ing used  has  been  sterile  gauze  in  two  pieces :  One  a  little  square  cut  on 
one  side  to  slip  around  and  fold  over  the  cord  (see  Fig.  236) ;  the  other 
a  long  strip  of  gauze  to  wrap  about  the  abdomen  of  the  child  and  serve 
as  a  band  to  hold  the  small  gauze  dressing  in  place. 

It  is  well  to  have  on  hand  a  number  of  cord  dressings  sterilized  and 
ready  for  use  as  shown  in  Fig.  236  C,  the  square  gauze  dressing  being 
rolled  within  the  gauze  band  and  both  surrounded  by  a  gauze  cover. 
The  cord  dressing  with  gauze  band  applied  to  the  baby  may  be  seen  in 
Fig.  237.  This  cord  dressing,  sterile  in  itself  and  applied  with  sterile 
hands,  is  not  removed,  unless  accidentally  soiled,  until  five  days  have 
elapsed.  If  the  outer  band  becomes  soiled  it  may  be  replaced  by  a  clean 
one.    In  a  consecutive  series  of  10,000  cases  at  the  Sloane  Hospital  the 


336 


THE  MANAGEMENT  OF  NORMAL  LABOR 


average  day  of  separation  of  the  cord  was  the  eighth.  After  the  cord  has 
separated  there  is  often  quite  a  core  or  stump  which  has  not  entirely 
healed.     The  best  treatment  for  the  stump  is  to  touch  it  every  day  or 


Fig.  236. — Cord  dressing:  A,  small  square  of  gauze  to  fold  around  and  over  cord;  B,  gauze 
band  to  hold  small  square  in'place;  C,  cord  dressing  rolled  up  w-ithin  muslin  cover. 


Fig.  2.37. — -Cord  dressing  applied  to  the  baby. 


two  with  a  nitrate  of  silver  stick  and  then  apply  a  pad  of  sterile  gauze 
without  powder.  This  treatment  should  be  continued  until  the  stump 
has  retracted  and  healed.    If,  after  the  stimip  has  retracted  out  of  sight 


MANAGEMENT  OF  THE  SECOND  STAGE  337 

there  is  still  a  little  discharge,  either  that  of  ordinary  granulation  or  a 
little  bloody  oozing  at  times,  the  depression  of  the  navel  should  be 
cleansed  with  a  little  sterile  cotton  on  a  sterile  wooden  toothpick  and  a 
little  8  per  cent,  nitrate  of  silver  solution,  or  a  little  powdered  alum  carried 
in  with  another  sterile  cotton  toothpick.  If  any  evidence  of  infection 
appears  about  the  navel  it  should  be  frequently  cleansed  with  a  sterile 
cotton  toothpick  and  a  wet  dressing  of  alum  acetate  solution  kept  on. 
The  application  of  tincture  of  iodin  of  half-strength  is  also  of  value. 

Treatment  of  the  Baby's  Eyes. — The  vernix  caseosa  having  been  removed 
and  the  cord  dressing  applied,  the  prophylactic  treatment  of  the  eyes  is 
completed  by  the  instillation  of  some  salt  of  silver.  At  present  the  author 
is  using  in  his  service  at  the  Sloane  Hospital  and  in  his  private  practice 
a  20  per  cent,  solution  of  argyrol. 

In  order  to  determine  the  best  silver  salt  for  the  prophylactic  treatment 
of  the  eyes  of  the  newborn  a  comparative  study  was  made  by  the  author, ' 
in  1907,  of  the  results  obtained  by  him  at  the  Sloane  Hospital  by  the 
use  in  five  different  series  of  cases  of  five  different  silver  solutions: 
Nitrate  of  silver,  2  per  cent.;  nitrate  of  silver,  1  per  cent.;  protargol, 
5  per  cent.;  argyrol,  10  per  cent.;  argyrol,  20  per  cent.  The  results  were 
as  follows: 

Series  I.  In  1000  confinements,  2  per  cent,  nitrate  of  silver  solution: 
Cases  of  ophthalmia,  18;  eyes  lost,  none;  opacities,  none. 

Series  11.  In  1000  confinements,  1  per  cent,  nitrate  of  silver  solution: 
Cases  of  ophthalmia,  34;  eyes  lost,  1;  opacities,  none. 

Series  III.  In  2000  confinements,  5  per  cent,  protargol  solution:  Cases 
of  ophthalmia,  53;  average  per  thousand,  26+;  eyes  lost,  1;  opacities,  1. 

Series  IV.  In  2000  confinements,  10  per  cent,  argyrol  solution:  Cases 
of  ophthalmia,  34;  average  per  thousand,  17;  eyes  lost,  1;  opacities,  2. 

Series  V.  In  2000  confinements,  20  per  cent,  argyrol  solution :  Cases 
of  ophthalmia,  43;  average  per  thousand,  21+ ;  eyes  lost,  none;  opacities, 
none. 

During  the  use  of  the  2  per  cent,  nitrate  of  silver  solution,  the  irrita- 
tion of  the  eyes  with  the  accompanying  edema  and  discharge,  the  so-called 
"silver  catarrh,"  was  so  great  that,  not  only  did  it  occupy  a  great  deal 
of  our  nurses'  time  in  applying  compresses  and  irrigating  the  babies' 
eyes,  but  it  seemed  to  be  a  source  of  danger,  not  only  by  leaving  an 
irritated  eye  which  might  later  become  infected,  but  also  by  causing 
in  our  nurseries  discharging  eyes  from  which  the  discharge  might  be 
carried  by  nurses  to  healthy  eyes,  and  thus  infection  produced.  For 
this  reason,  although  no  eyes  were  lost  in  this  series,  and,  as  fa?-  as  known, 
no  opacities  produced,  the  strength  of  the  nitrate  of  silver  solution  was 
reduced  from  2  per  cent,  to  1  per  cent.  The  author  has  stated  above 
"as  far  as  known"  for  the  reason  that  in  this  series  of  1000  confinements 
5  babies  were  taken  from  the  hospital  with  ophthalmia  miimproved 
and  against  advice,  in  whom  the  ultimate  result  is  unknown  to  the  writer. 


1  Cragin,  The  Prophylactic  and  Curative  Treatment  of  Ophthalmia  Neonatorum,  Trans. 
Amer.  Gyn.  Soc,  1907. 
22 


338  THE  MANAGEMENT  OF  NORMAL  LABOR 

In  this  same  series  2  babies  died  witli  ophthalmia  uncured.  In  the 
second  series,  with  the  use  of  the  1  per  cent,  nitrate  of  silver  solution,  the 
lessened  irritation  of  the  eye  seemed  a  great  improvement;  but,  as  shown 
above,  there  occurred  34  cases  of  ophthalmia,  nearly  twice  as  many  as 
in  the  previous  series,  and,  in  addition,  one  eye  was  lost  by  perforation 
of  the  cornea.  It  looked  as  though  the  lessened  irritation  had  been 
gained  at  the  expense  of  protection,  and  for  this  reason  the  use  of  the  1 
per  cent,  nitrate  of  silver  solution  was  abandoned.  At  this  time  the  use 
of  protargol  came  to  the  author's  notice,  and  in  the  next  series  of  2000 
confinements  a  5  per  cent,  protargol  solution  was  used  as  a  prophylactic 
measure.  The  irritation  was  lessened,  but,  in  this  series,  although  there 
were  fewer  cases  of  ophthalmia  than  with  the  use  of  1  per  cent,  nitrate 
of  silver  solution,  one  eye  was  lost  and  there  was  one  opacity. 

In  the  next  series  of  2000  confinements,  10  per  cent,  argyrol  solution 
was  used  with  the  following  results:  The  number  of  cases  of  ophthalmia 
per  thousand  was  17,  the  smallest  number  in  any  series  of  the  8000  cases; 
there  was  a  complete  absence  of  irritation,  and  the  drug  was  a  safe  one 
for  a  nurse  to  apply  at  frequent  intervals  in  case  ophthalmia  developed. 

Unfortunately  in  this  series  of  2000  confinements,  one  eye  was  lost, 
and  two  babies  left  the  hospital  with  a  small  opacity  of  one  cornea.  For 
this  reason  it  seemed  to  the  author  that  in  spite  of  the  reduction  in  the 
number  of  cases  per  thousand,  the  protection  was  insufficient,  and,  there- 
fore, in  the  next  series  of  2000  confinements  the  strength  of  the  argyrol 
solution  as  a  prophylactic  measure  was  increased  to  20  per  cent. 

In  this  series  no  eyes  were  lost,  there  were  no  opacities  of  the  cornea, 
and  no  babies  left  the  hospital  with  a  purulent  discharge.  For  reasons 
w^hich  will  be  given  later,  however,  the  number  of  cases  of  ophthalmia 
was  larger  than  in  the  preceding  series,  that  is,  21+  per  thousand.  This 
series  covered  a  period  in  which  there  was  an  epidemic  of  so-called  "  pink 
eye"  in  New  York  City;  and,  as  no  gonococci  were  found  in  the  eyes  of 
the  babies  during  the  month,  it  was  thought  by  the  ophthalmologist, 
who  saw  some  of  the  cases  in  consultation,  that  they  were  cases  of  pink 
eye.  On  comparison  of  the  results  in  the  five  different  series  it  will  be 
seen  that  Series  V,  treated  with  20  per  cent,  argyrol,  surpasses  all  the 
others  save  Series  I,  in  which  2  per  cent,  nitrate  of  silver  was  used;  and 
when  it  is  noted  that  in  this  series  five  babies  left  the  hospital  with 
ophthalmia  uncured,  Avhile  in  Series  V  no  baby  left  the  hospital  with  a 
purulent  discharge  from  either  eye,  it  seems  to  the  author  that  Series 
\  should  receive  the  preference. 

In  addition  to  this,  the  freedom  in  Series  V  from  the  silver  catarrh, 
with  its  demand  for  cold  compresses,  frequent  irrigations,  and  frequent 
attentions  from  .the  nurses,  so  pronounced  in  Series  I,  has  proved  a  great 
boon  to  the  hospital  regime. 

Viewed  from  the  clinical  standpoint  alone,  the  method  employed  in 
Series  V  seemed  the  most  satisfactory,  but  that  he  might  have  a  reason 
for  the  faith  which  lay  within  him  the  author  had  made  for  him  a  series 
of  very  careful  investigations  concerning  the  bactericidal  power  of  the 


MANAGEMENT  OF  THE  SECOND  STAGE 


339 


silver  salts  used  in  the  different  series.  The  tests  were  made  with  the 
Staphylococcus  pyogenes  aureus,  the  Streptococcus  pyogenes,  and  the 
gonococcus  and  were  made  in  duplicate.  The  method  of  procedure  was 
to  transfer  the  cultures  to  the  disinfectant  solutions  of  different  strengths 
for  the  various  times,  and  then  again  from  them  to  large  tubes  of  broth 
holding  50  c.c.  each.  In  this  way  any  chance  of  the  small  amount  of 
disinfectant  which  might  still  cling  to  the  organisms  having  any  restrain- 
ing action  on  the  growth  was  eliminated  by  the  large  quantity  of  broth 
used. 

In  the  case  of  the  gonococcus  two  strains  of  the  organism  were  secured, 
one  of  which  was  a  very  sturdy  grower.  Both  of  these  were  used  as  a 
check  upon  each  other  in  the  case  of  argyrol  and  similar  results  were 
obtained  in  both  cases.    The  gonococcus  was  cultivated  in  ascitic  broth. 

The  times  of  exposure  were  from  thirty  seconds  to  thirty  minutes  in 
the  cases  of  the  Streptococcus  pyogenes  and  the  gonococcus;  and  from 
thirty  seconds  to  twelve  minutes,  in  the  case  of  the  Staphylococcus 
pyogenes  aureus. 

In  the  results  which  follow  the  minus  signs  indicate  no  growth.  The 
plus  signs  indicate  a  growth: 


NITRATE  OF  SILVER  SOLUTIONS. 


Time. 

30  seconds  . 

1  minute 

2  minutes 

3  minutes 
5  minutes 

12  minutes 
20  minutes 
30  minutes 


2  per  cent. 


Streptococcus 
1  per  cent. 


Ptogexes. 
i  per  cent. 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


:s. 

I  per  cent.    V")  per  cent,    ^j-s  per  cent. 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


Time. 

30  seconds 

1  minute 

2  minutes 

3  minutes 
5  minutes 

12  minutes 


Staphylococcus  Pyogenes  Aureus. 

2  per  cent.  1  per  cent.  J  per  cent.  j  per  cent,    'jio  per  cent,  '/m  per  cent. 

++  ++  +  + 

--  ++  ++  +  + 

--                ++  ++  +  + 

--                ++  ++  +  + 

--                ++  ++  +  + 

++  ++  +  + 


Time. 

30  seconds 

1  minute 

2  minutes 

3  minutes 
5  minutes 

12  minutes 
20  minutes 
30  minutes 


Gonococcus. 
2  per  cent.  1  per  cent. 


5  per  cent. 


i  per  cent. 


340 


THE  MANAGEMENT  OF  NORMAL  LABOR 


Time. 
30  seconds 

1  minute 

2  minutos 
'.i  minutes 
5  minutes 

12  minutes 
20  minutes 
30  miiuites 


o  per  cent. 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


PROTARGUL  SOLUTIONS. 

Stkeptococcus  Pvogenes. 
2  per  cent.        1  per  cent. 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


per  cent. 

J  per  cent. 

/ii)  per  cent 

+    + 

+     + 

+    + 

+    + 

+     + 

+     + 

+    + 

+     + 

+    + 

+    + 

+     + 

+    + 

+    + 

+     + 

+    + 

+    + 

+     + 

+    + 

+    + 

+     + 

+    + 

+    + 

+    + 

+    + 

Time. 
30  seconds 

1  minute 

2  minutes 

3  minutes 
5  minutes 

12  minutes 


o  per  cent. 


Staphylococcus  Pvogenes  Aureus. 
2  per  cent.      1  per  cent,  i   per  cent,    j  per  cent. 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


percent,   '/so  per  cent. 


+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


+  + 

+  + 

+  + 

+  + 

+  .+ 

+  + 


Time. 
30  seconds 

1  minute 

2  minutes 

3  minutes 
5  minutes 

12  minutes 
20  minutes 
30  minutes 


G  )Xoct)CCU.s. 
5  i)er  cent.      2  per  cent. 

-  -  +  + 

-  -  +  + 

-  -  +  + 


1  per  cent. 

+  + 
+  + 
+  + 
+  + 
+  + 


per  cent. 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 

+  + 


ARGYROL  SOLUTIONS. 

Stheptococcu.s  Pyogenes. 


Time. 

30  per  cent.             20  per  cent. 

10  per  cent. 

.'  i)er  cent. 

1  per  cent 

30  seconds  ....++                   +    + 

+     + 

+     + 

+     + 

1  minute    .... 

+     +                       +     + 

+     + 

+     + 

+     + 

2  minutes 

+     +                       +    + 

+     + 

+     + 

+     + 

3  minutes 

+     +                       +     + 

+     + 

+     + 

+     + 

5  minutes 

+     +                       +     + 

+     + 

+     + 

+     + 

12  minutes 

+     +                       +     + 

+     + 

+     + 

+     + 

20  miiuites 

+     +                       +     + 

+     + 

+     + 

+     + 

30  minutes 

+    +                       +     + 

+    + 

+     + 

+    + 

Sr.\PHYLococcu.s  Pyooe.ntes  Aureus. 

Time.                                  30  per 

cent.         20  per  cent. 

10  i)cr  cent. 

2 

pi'r  cent. 

1  per  cent. 

30  seconds  ....++                   +    + 

+     + 

+     + 

+     + 

1  mimite    ....++                   +    + 

+    + 

+     + 

+     + 

2  minutes         .      .      .      +    +                   +    + 

+     + 

+     + 

+    + 

3  minutes        .      .      .       +    +                   +    + 

+     + 

+     + 

+     + 

5  minutes        .      .      .       +    +                   +    + 

+    + 

+    + 

+     + 

12  miiuites        .      .      .      +    +                   +    + 

+    + 

+    + 

+     + 

G0NOCOCCU.S. 

Time. 

30  per  cent.                20  per  cent. 

10  per  cent. 

2  per  cent. 

30  seconds 

_     _                          _ 

- 

+ 

+ 

+    + 

1  minute 

_     _                          _ 

— 

+ 

+ 

+    + 

2  minutes 

_     _                           _ 

— 

+ 

+ 

+    + 

3  minutes 

_     _                          _ 

— 

+ 

+ 

+    + 

5  minutes 

_     _                          _ 

— 

+ 

+ 

+    + 

12  minutes 

_     _                          _ 

— 

+ 

+ 

+    + 

20  minutes 

_     _                          _ 

— 

— 

— 

+    + 

30  minutes 

_     _                           _ 

— 

— 

— 

+    + 

MANAGEMENT  OF   THE   THIRD  STAGE  341 

From  the  foregoing  tests  it  is  evident  that  in  the  solutions  usually 
employed,  argyrol  has  practically  no  bactericidal  power  over  the  strepto- 
coccus or  staphylococcus;  but  with  the  gonococcus,  in  strengths  of 
20  per  cent,  and  30  per  cent.,  it  is  perfectly  efficient.  These  tests  also 
show  why  the  results  with  the  10  per  cent,  argyrol  were  not  as  good  as  with 
the  20  per  cent,  argyrol. 

So  long  as  a  20  per  cent,  argyrol  solution  is  efficiently  bactericidal 
with  the  gonococcus  in  thirty  seconds;  so  long  as  the  gonococcus  is  the 
coccus  most  feared  in  the  etiology  of  ophthalmia  neonatorum,  and  so 
long  as  the  clinical  results  are  practically  as  good  as  with  the  use  of  2 
per  cent,  nitrate  of  silver,  and  better  than  with  1  per  cent,  nitrate  of 
silver,  and  this  without  the  annoyances  of  silver  irritation  and  staining, 
the  author  feels  justified  in  using  and  advocating  the  use  of  argyrol  as  a 
prophylactic  against  ophthalmia  neonatorum.  The  instillation  of  the  20 
per  cent,  argyrol  solution  is  repeated  on  the  third  day  of  the  puerperium. 
After  the  prophylactic  treatment  of  the  eyes,  the  baby  is  weighed  (one 
ounce  being  deducted  for  the  weight  of  the  cord  dressing),  is  wrapped  in 
a  blanket  mid  kept  warm  with  a  hot-water  bag  placed  not  too  near  it, 
w^hile  attention  is  directed  to  the  care  of  the  mother. 

MANAGEMENT  OF  THE  THIRD  STAGE. 

Expression  of  the  Placenta. — With  the  birth  of  the  child  the  second 
stage  ends  and  the  third  or  placental  stage  begins.  During  this  period 
the  fundus  of  the  uterus  is  guarded  by  the  nurse,  who  having  discon- 
tinued the  use  of  the  anesthetic  with  the  birth  of  the  child's  head, 
follows  dowTi  the  fundus  with  her  hand  upon  it  as  the  physician  delivers 
the  body  of  the  child  and  then  guards  the  fundus  during  the  period  of 
placental  separation  while  the  physician  is  ligating  and  cutting  the 
cord,  removing  the  vernix  caseosa,  applying  the  cord  dressing,  washing 
the  baby's  eyes,  etc.  During  the  placental  or  third  stage  the  objects 
desired  are  the  separation  of  the  placenta;  the  avoidance  of  excessive 
hemorrhage;  the  expulsion  of  the  placenta  and  the  contraction  of  the 
uterus.  For  the  securing  of  these  objects  time  should  be  allowed  for 
placental  separation  and  during  this  time  the  fundus  should  be  carefully 
guarded  by  the  hand  of  the  nurse.  It  is  important  that  the  obstetrician 
should  ascertain  that  the  nurse  has  found  the  fundus  with  her  hand 
and  that  she  is  holding  and  guarding  that  rather  than  the  sjTuphysis 
pubis  which  the  author  has  known  nurses  to  mistake  for  it. 

The  nurse  should  hold  the  fundus  in  the  palm  of  her  hand  with  suffi- 
cient manipulation  of  it  to  prevent  ballooning,  but,  unless  hemorrhage 
occurs,  without  force  enough  to  cause  distress  to  the  patient,  in  this 
way  allowing  time  for  the  separation  of  the  placenta.  The  time  of  wait- 
ing for  placental  separation  varies  in  the  practice  of  different  practi- 
tioners from  fifteen  to  thirty  minutes.  At  the  Sloane  Hospital  the 
routine  procedure  is  to  wait  twenty  minutes  from  the  birth  of  the  child 
before  efforts  at  expressing  the  placenta  are  undertaken.  In  case  a 
hemorrhage  occurs  the  fundus  is  manipulated  vigorously  until  either 
the  hemorrhage  ceases  or  the  placenta  is  expressed. 


342 


THE  MANAGEMENT  OF  NORMAL  LABOR 


At  the  expiration  of  the  twenty  minutes  from  the  birth  of  the  ciiild  the 
obstetrician  takes  the  fundus  and  expresses  the  placenta  by  the  Crede 
method.  Standing  at  the  patient's  riglit  lie  seizes  the  fundus  with  his 
left  hand,  his  thumb  being  in  front  and  fingers  behind  the  fundus,  and 
makes  forcible  compression  of  it  at  the  same  time  that  he  presses  the 
fundus  downward  in  the  axis  of  the  parturient  canal  (see  Figs.  238,  239, 
and  240).  This  compression  should  be  carried  out  during  a  uterine 
contraction  and   there  may  be  several   attempts  necessar}'  before  the 


Fig.  238. — Crede  method  of  expressing  the  placenta. 


placenta  is  delivered;  each  attempt  at  expression,  howe^■e^,  should  be 
undertaken  during  a  uterine  contraction,  as  downward  pressure  on  an 
uncontracted  uterus  will  in  some  cases  easily  cause  inversion.  As  the 
placenta  emerges  from  the  ^•ulva  it  is  received  in  the  palm  of  the  right 
hand  which  supports  it  as  the  membranes  are  trailing  out  of  the  vagina. 
The  plan  of  placental  delivery  should  be  expression  from  above  rather 
than  traction  from  below. 

The  membranes  should  not  be  twisted,  as  this  is  very  apt  to  tear  them. 
Ample  time  should  be  given  for  their  separation  and  then  the  hand  hold- 


MANAGEMENT  OF   THE   THIRD  STAGE 


343 


ing  the  placenta  may  be  moved  a  little  up  and  douai  to  facilitate  the 
delivery  of  the  membranes.  After  the  birth  of  the  placenta  it  should  be 
spread  out,  maternal  surface  upward,  and  carefully  examined  for  missing 
or  lacerated  cotyledons  or  evidence  that  some  of  the  structure  of  the 
placenta  is  lacking. 

It  should  then  be  turned  over  and  the  fetal  surface  examined,  the 
amniotic  sac  being  opened  to  see  if  sufficient  membranes  are  present  to 
construct  a  sac  large  enough  to  contain  the  fetus.  If  a  considerable 
portion  of  the  placenta  itself  is  lacking,  the  author's  practise  is  to  redis- 


FiG.  239. — Crede  method.     Placenta  distending  vulva. 

infect  one  gloved  hand  or  put  on  a  sterile  glove  and  go  into  the  uterus  for 
the  missing  portion.  Also  if  a  large  portion  of  the  amnion  or  chorion  is 
lacking  the  same  method  is  followed,  but  if  only  a  small  portion  of  the 
amnion  and  chorion  is  missing  this  is  left  to  come  away  with  the  lochia. 

If  a  small  portion  of  the  membranes  is  seen  to  be  retained  in  the 
cervix  and  vagina  this  is  carefully  removed  by  the  sterile  fingers. 

With  the  complete  expulsion  of  the  placenta  a  dose  of  the  fluidextract 
of  ergot  (1  to  2  drams),  or  some  other  preparation  of  ergot  is  given  to  main- 
tain the  contraction  of  the  uterus,  this  tending  not  only  to  prevent 
hemorrhage  but  infection. 


344 


THE  MANAGEMENT  OF  NORMAL  LABOR 


No  douches,  either  vaginal  or  intra-iiterine,  should  be  given  save  for 
two  indications:  (a)  To  control  hemorrhage,  (b)  To  wash  away 
debris  which  has  been  loosened  by  the  fingers.  After  the  deliver}^  of 
the  placenta  the  pelvic  floor  should  be  carefully  examined  for  lacera- 
tions. It  is  not  sufficient  simply  to  inspect  the  skin  surface  of  the  peri- 
neum and  decide  from  this  that  no  laceration  has  occurred.  The  skin 
surface  even  to  the  fourchette  may  remain  intact  and  yet  extensive 
lacerations  may  have  occurred — lacerations  which  have  involved  the 
fascia  binding  together  the  levatores  ani,  thus  producing  one  of  the  most 
important  lesions  of  the  pelvic  floor. 


Fig.  240. — Ciedc  method.     Placenta  emerging  from  vulva. 

Not  only  should  the  skin  surface  of  the  perineum  be  inspected,  but 
the  labia  should  be  separated,  and  if  tears  are  found  in  either  sulcus  these 
should  be  sutured  as  will  be  discussed  later  (see  page  726).  In  regard 
to  the  immediate  repair  of  lacerations  of  the  cervix,  it  is  the  consensus 
of  opinion  among  obstetricians  today  that,  save  for  the  deep  lacerations 
causing  hemorrhage,  the  wisest  course  lies  in  leaving  lacerations  of  the 
cervix  alone  during  the  puerperal  weeks.  The  author  is  strongly  convinced 
that  the  necessary  manipidation  incident  to  the  examination  and  ex- 
posure of  lacerations  of  the  cervix  and  the  danger  of  closing  the  cervical 
canal  so  tightly  as  to  interefere  with  uterine  drainage  tend  so  often  to 
the  development  of  infection  and  subinvolution  as  to  furnish  a  very  strong 


GAURDING  THE  FUNDUS 


345 


argument  against  the  immediate  repair  of  lacerations  of  the  cervix  unless 
marked  cervical  hemorrhage  occurs. 

After  the  delivery  of  the  placenta  and  the  repair,  if   necessary,  of 
lesions  of  the  pelvic  floor,  the  vuh'a  is  cleansed  and  a  drv  sterile  absorbent 


Fig.  241. — A,  breast  binder;  B,  abdominal  binder. 


Fig.  242. — Abdominal  binder  and  breast  binder  applied. 


vulva  pad  is  applied.  The  mother  now  should  be  allowed  to  rest  but 
the  fimdus  of  the  uterus  should  be  held  and  guarded  by  the  hand  of  the 
nurse  until  it  is  evident  that  the  uterus  will  remain  well  contracted, 
i.  c,  at  least  an  hour  from  the  birth  of  the  child.    At  the  expiration  of 


346  THE  MANAGEMENT  OF  NORMAL  LABOR 

this  period  the  abdominal  binder  may  be  applied.  Tlie  abdominal  and 
breast  binders  as  employed  at  the  Sloane  Hospital,  before  and  after 
application  are  shown  in  Figs.  241  and  242. 

Abdominal  Binder. — The  release  of  the  abdominal  wall  from  the  ten- 
sion to  which  it  has  been  subjected  for  months  leaves  it  so  lax  that  the 
woman  is  inclined  to  feel  uncomfortable  unless  some  abdominal  support 
is  applied.  For  this  reason  the  abdominal  binder  may  be  looked  upon  as 
a  source  of  comfort  at  least  during  the  first  few  days  of  the  puerperium. 
Furthermore,  a  snugly  fitting  binder  tends  to  prevent  ballooning  of  the 
uterus  with  its  accompanying  hemorrhage  and  thus  serves  as  a  factor 
in  safety  as  well  as  comfort. 

After  the  fifth  day  the  choice  between  continuing  the  binder  and  dis- 
carding it  may  largely  be  left  to  the  patient  and  in  hot  weather  she  is 
usually  more  comfortable  without  it  after  the  first  week.  As  soon  as  the 
uterus  has  involuted  sufficiently  to  descend  into  the  pelvis  it  should  be 
borne  in  mind  that  retroversion  of  it  is  possible  for  the  reason  that  the 
round  ligaments  have  not  yet  regained  their  tone  and  the  uterine  body  is 
heavier  than  normal.  Such  being  the  case  it  is  important  that  the  binder 
if  worn  after  the  first  week  should  not  be  applied  too  tightly  and,  further- 
more, the  patient  should  be  urged  not  to  lie  continuously  on  her  back. 
She  should  lie  for  a  time  on  one  side  then  on  the  other  and  as  soon  as 
the  breasts  have  lost  their  sensitiveness,  she  may  lie  for  a  time  each 
day  on  her  abdomen. 

Postpartum  Chill. — Very  frequently  the  patient  immediately  following 
the  completion  of  the  third  stage  will  experience  quite  a  pronounced 
rigor.  This  is  purely  a  vasomotor  disturbance  of  little  moment  and  re- 
quires for  its  treatment  only  a  warm  blanket  and  a  hot-water  bag  or  a 
warm  electric  pad  applied  to  the  feet.  Its  occurrence  is  usually  explained 
by  the  sudden  diminution  in  heat  production  due  to  the  cessation  of 
muscular  effort  and  by  the  heat  loss  through  perspiration,  etc. 

If  the  uterus  is  well  contracted,  the  lochia  moderate  in  amount,  and 
the  pulse  slow  and  strong,  the  obstetrician  can  usually  leave  his  patient 
with  safety  in  about  an  hour  from  the  birth  of  the  child.  The  nurse  should 
be  instructed  to  take  the  temperature,  pulse  and  respiration  of  the  mother 
every  four  hours  during  the  daytime  for  the  first  few  days  and  after  that, 
if  the  puerperium  seems  normal,  twice  a  day  will  suffice.  The  tempera- 
ture of  the  baby  should  be  taken  night  and  morning.  The  nurse  should 
also  be  told  to  catheterize  the  patient  every  eight  hours  if  she  is  unable 
to  void  her  urine,  to  give  her  a  tablet  of  codein,  gr.  ss,  repeated  in  two 
hours  if  needed  for  after-pains;  to  let  the  baby  go  to  the  breast  for  five 
minutes  after  the  mother  has  had  a  rest  and  to  bathe  the  baby  on  the 
lap  at  any  time  after  six  hours  from  birth. 

Clothing  of  the  Baby. — After  the  baby  has  been  bathed  on  the  lap 
it  may  be  dressed.  The  advice  of  the  obstetrician  is  often  asked  regard- 
ing the  clothing  of  the  expected  child  and  it  is  important  that  he  should 
be  well  informed  on  this  subject,  for  one  of  the  agreeable  pastimes  of  the 
expectant  mother  during  her  trying  months  of  waiting  is  the  preparation 
of  the  clothing  for  the  anticipated  child.      Of  course  the  obstetrician 


CLOTHING  OF   THE  BABY  347 

in  his  advice  regarding  dress  can  only  deal  with  principles.  The  mother 
will  delight  in  getting,  and  the  friends  m  sending,  all  sorts  of  dainty  make- 
ups for  the  head  and  feet  of  the  baby  and  with  these  the  obstetrician 
need  not  concern  himself.  There  are,  however,  four  principal  articles 
in  the  clothing  of  the  baby  m  which  the  obstetrician  is  deeply  interested, 
and  these  articles  are  shown  in  the  accompanying  Fig.  243.    They  are: 


A  C 

Fig.  243. — Clothing  of  the  baby:  A,  flannel  band;  B,  short  flannel  shirt;  C,  long  flannel  slip; 

D,  long  muslin  slip. 

1.  A  flannel  hand  which  is  to  be  used  from  the  time  the  sterile  dress- 
ing of  the  navel  is  dispensed  with  until  the  baby  is  four  or  five  months 
old.  This  not  only  gives  warmth  to  the  baby's  abdomen  but  furnishes 
support  to  the  umbilicus,  tending  to  prevent  hernia  from  crjang  of  the 
baby,  should  there  be  any  tendency  to  umbilical  weakness.  The  band 
is  better  sewed  with  a  loose  running  stitch  rather  than  pinned,  and  care 
should  be  taken  that  it  is  applied  firmly  enough  to  give  a  gentle  support 
to  the  abdomen  and  not  tightly  enough  to  crowd  up  the  stomach  and 
interfere  with  its  digestion. 

2.  A  short  flannel  shirt. 


348 


THE  MANAGEMENT  OF  NORMAL  LABOR 


3.  A  long  Jianncl  dip,  long  enough  to  come  well  below  the  baby's  feet 
so  that  it  can  be  folded  over  to  keep  the  feet  warm. 


Fig.  244. — Wa.shing  of  the  face  and  scalp. 

4.  A  long  muslin  slip;  this  may  be  plain  or  decorated  with  sufficient 
ribbons  and  embroiderv  to  satisfv  the  daintiest  of  tastes. 


Fig.  24.5. — Bain-  in  the  tub. 


The  Baby's  Bath. — Until  the  cord  has  separated  and  the  na\el  has 
healed  the  baby  is  bathed  on  the  lap  of  the  nurse  and  the  navel  is  kept 


THE  BABY'S  BATH 


349 


I'lii.   IMC). — Drying  hi\hy  on  the  lap. 


Fig.  247. — Sewing  on  the  band.    Weighing  the  baby. 


350  THE  MANAGEMENT  OF  NORMAL  LABOR 

dry.     With  the  heahng  of  the  navel,  however,  the  baby  is  ready  for  its 
tub  l)ath  which  should  be  given  daily  just  before  one  of  its  morning 

feedings.        O^^r-V   ^  .U-C^   a<-n>-M^  ^-.^> 

For  this  purpose  there  are  needed  'a  bath-tub  which  can  be  easily 
cleansed,  some  clean,  pure  soap,  a  thermometer,  and  either  a  soft  wash- 
cloth which  can  be  easily  laundered  and  sterilized,  or  sterile  gauze  or 
cotton  which  can  be  used  and  throwji  away.  The  temperature  of  the 
water  is  very  important  and  should  range  from  98°  to  102°  F.  Xo  nurse, 
even  with  a  thermometer,  should  ever  put  a  baby  in  a  tub  of  water  with- 
out first  testing  the  temperature  of  the  water  with  her  hand.  The  neglect 
of  this  simple  precaution  cost  the  life,  from  scalding,  of  the  baby  of  one 
of  the  author's  intimate  friends.  The  first  step  in  the  bath  should  be 
the  washing  of  the  face  and  scalp,  and  this  should  be  done  on  the  lap 
of  the  nurse  before  the  baby  is  put  in  the  tub  (see  Fig.  244).  For  the 
scalp,  clean  soap  should  be  used  on  the  wash-cloth.  With  the  face  and 
scalp  cleaned,  especially  in  all  creases,  such  as  behind  the  ears,  the  baby 
is  ready  to  have  its  clothing  removed  and  be  lifted  gently  into  the  tub 
of  water  (see  Pig.  245),  the  temperature  of  which  has  been  carefully  tested. 
After  carefully  washing  all  parts  of  the  body,  especially  in  the  creases, 
the  baby  is  lifted  onto  the  lap  of  the  nurse  on  which  is  spread  a  soft  towel 
which  is  at  once  folded  about  the  l)al)y  so  that  chilling  from  exposure 
is  avoided  (see  Fig.  246).  By  gently  patting  the  towel  about  the  baby 
the  skin  is  dried.  The  creases  are  then  dusted  with  talcum  powder  and 
the  baby  is  ready  for  the  four  articles  of  clothing  just  described,  the 
band  being  sewed  on  (see  Fig.  247)  rather  than  pinned. 


CHAPTER  X. 

CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH. 

The  preceding  description  applies  to  the  care  of  the  child  in  normal 
condition.  Not  infrequently,  however,  the  condition  of  the  child  is 
abnormal  at  birth  either  from  asphyxia  or  on  account  of  being  premature 
and  of  undersize  and  underweight. 

ASPHYXIA   NEONATORUM. 

Differential  Diagnosis. — This  condition  must  first  be  differentiated  from 
apnea  which  is  the  normal  condition  of  the  fetus  in  utero  as  long  as  it 
receives  sufficient  oxygen  through  the  placenta  and  cord.  The  apnea 
may  also  continue  for  a  short  time  after  the  fetus  has  reached  the  outside 
world,  provided  the  placenta  is  still  attached  to  the  uterus  and  the  cord 
is  pulsating.  The  child  does  not  breathe  because  it  is  already  sufficiently 
oxygenated.  This  is  altogether  different  from  asphyxia  in  which  there 
is  insufficient  oxygenation. 

Etiology.^ — ^Asphyxia,  or  insufficient  oxygenation  of  the  fetus,  may  arise 
from  various  causes.  In  the  first  place  anything  interfering  with  the 
ready  flow  of  fetal  blood  through  the  placenta  in  close  proximity  to  the 
maternal  blood  and  through  the  cord  to  the  fetus  tends  to  produce 
asphjoda.  Thus  premature  separation  of  the  placenta,  tonic  compres- 
sion of  the  placenta  by  tonic  contraction  of  the  uterus,  and  compres- 
sion of  the  cord  would  all  act  to  lessen  the  oxygenation  of  the  fetus. 
Cerebral  compression  in  the  fetus  with  slowing  of  the  fetal  heart  would 
lessen  oxygenation  in  another  way.  The  condition  of  the  blood  of  the 
mother,  as  during  eclamptic  seizures  when  her  oxygenation  is  insufficient, 
may  cause  a  lack  of  oxygenation  in  the  fetal  blood.  These  may  all  act 
while  the  fetus  is  in  utero.  On  the  other  hand,  the  fetal  head  including 
the  face  may  be  too  long  delayed  in  the  vagina  and  from  a  short  cord,  or 
a  compressed  cord  or  from  a  prematurely  separated  placenta,  sufficient 
oxygenation  through  placenta  and  cord  is  not  obtained  by  the  fetus  and  it 
suffocates.  The  same  would  apply  if  the  placenta  was  separated  and 
the  membranes  were  unruptured  or  were  tight  over  the  face  of  the  child. 

Again,  if  the  cord  has  been  compressed  and  the  child  has  made  efforts 
to  breathe  in  utero,  the  msufflation  of  liquor  amnii,  mucus  and  even  meco- 
nium into  the  air  passages  interferes  with  the  entrance  of  air  after  birth. 

Finally,  in  premature  infants  the  nerve  and  muscular  development 
may  be  so  imperfect  that  the  normal  process  of  respiration  cannot  be 
carried  on. 

Pathology. — The  pathological  findings  in  asphyxia  neonatormn  vary 
with  the  cause  of  the  asphjofia  and  the  rapidity  of  its  development.    In 

(351) 


352      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

general,  more  or  less  atelectasis  is  found  with  engorgement  of  the  right 
heart  and  pulmonary  vessels.  There  is  congestion  of  the  viscera  with 
frequent  ecchymoses  and  depending  upon  the  amount  of  cerebral  com- 
pression, lesions  varying  from  edema  of  the  brain  and  its  membranes  to 
cerebral  hemorrhages  of  considerable  size.  If  intra-uterine  or  intra  vaginal 
efforts  at  respiration  have  been  made  the  trachea  and  bronchi  may  be 
found  filled  with  mucus,  amniotic  fluid  and  even  meconium. 

Antepartum  Diagnosis. — There  are  certain  evidences  of  impending  intra- 
uterine asphyxia  which  are  important  enough  to  deserve  consideration. 
The  most  valuable  are  the  following: 

(a)  Change  in  the  fetal  heart  sounds. 

(6)  The  passage  of  liquor  amnii  stained  with  fresh  meconium  in  pre- 
sentations other  than  breech. 

(c)  Tumultuous  movements  of  the  fetus. 

(d)  JNIarked,  persistent  umbilical  souffle. 

Of  these  different  signs  the  persistent  slowing  of  the  fetal  heart  beats 
froms^J3Q^  14\to  100  or  below  is  the  most  valuable  as  indicating  undue 
compression  and  threatened  asphyxia  and,  as  a  rule,  should  be  regarded 
as  an  indication  for  hastening  the  deliver^'. 

The  change  from  a  slow  fetal  heart  to  one  that  is  ^•ery  rapid  or 
irregular  is  frequently  a  sign  of  disturbed  fetal  circulation  and  perhaps 
impending  asphjT^ia,  but  is  less  to  be  depended  on  than  the  marked 
slowing  of  the  fetal  heart  mentioned  above. 

The  appearance  of  fresh  meconium  in  the  liquor  ammi  in  cases  other 
than  breech  is  a  strong  evidence  of  disturbed  fetal  circulation  and  threat- 
ened asphyxia,  and  especially  when  associated  with  slow  fetal  heart 
sounds,  should  be  considered  as  indication  for  hastening  the  delivery. 

Not  infrequently,  just  before  the  death  of  the  child  in  ntero,  the  mother 
notices  tumultuous  movements  of  the  child;  these  may  indicate  asphyxia 
and  attempts  at  respiration  during  its  death  struggle.  Taken  by  them- 
selves these  tumultuous  movements  are  not  often  a  sign  of  great  impor- 
tance but  coupled  with  very  slow  heart  sounds  and  the  passage  of  mecon- 
ium into  the  liquor  amnii,  they  become  a  serious  indication  of  asphyxia. 

The  same  may  be  said  of  the  persistent  umbilical  souffle.  While 
alone  it  is  often  a  sign  of  little  moment,  when  found  associated  with 
other  signs  of  disturbed  fetal  circulation  it  may  form  a  sufficiently  strong 
corroborative  evidence  of  threatened  asphyxia  to  indicate  hastening  of 
the  deli^'ery. 

Clinical  Picture. — Clinically  there  are  two  types  of  asphyxia  presented 
by  the  baby.  In  one  the  muscle  tone  is  retained  and  the  child  is  c>'anotic. 
This  is  usually  called  asphyxia  livida.  In  the  other  the  muscular  system, 
including  the  sphincters,  is  relaxed,  and  the  child  is  pale  and  the  con- 
dition is  called  asphyxia  pallida.  The  prognosis  of  asphyxia  livida  is 
usually  better  than  that  of  asphyxia  pallida,  although  the  child  is  often 
resuscitated  from  either  condition.  The  passing  of  the  child  from  the 
condition  of  asphyxia  livida  to  that  of  asphyxia  pallida,  as  sometimes 
happens,  usually  indicates  a  bad  prognosis  and  the  return  of  muscular 
contraction  in  an  asphyxia  pallida  usually  means  a  good  prognosis. 


ASPHYXIA   NEONATORUM  353 

Treatment. — In  the  treatment  of  asphyxia  neonatorum  there  are  three 
chief  indications: 

1 .  To  clear  the  upper  air  passages. 

2.  To  perform  artificial  respiration. 

3.  To  employ  reflex  stimulation  of  respiration. 

These  three  indications  can  be  met  in  several  ways,  but  in  whatever 
method  that  may  be  selected,  it  should  be  borne  in  mind  that  an  asphyx- 
iated newborn  baby  is  a  delicate  structure  of  low  vitality  and  great  care 
should  be  taken  not  to  injure  its  structure  or  lower  its  vitality. 

Clearing  the  Upper  Air  Passages. — For  clearing  the  upper  air  pas- 
sages which  may  be  filled  with  mucus,  liquor  amnii,  etc.,  a  good  method  is 
to  hold  the  baby,  wrapped  in  a  sterile  towel,  with  head  down  and  then 
gently  slap  its  buttocks.  This  not  only  allows  the  obstructing  fluid  to 
run  out  but  often  stimulates  respiration  from  the  slapping.  In  addition 
to  this,  a  method  often  employed  at  the  Sloane  Hospital  is  to  use  a 
''blow-out"  so-called,  i.  e.,  to  have  the  nurse  place  a  fold  of  sterile  gauze 
over  the  mouth  of  the  baby,  indenting  the  gauze  over  the  baby's  mouth 
so  as  to  mark  its  location.  The  obstetrician  then  blows  through  the 
gauze  into  the  baby's  mouth  at  the  same  time  holding  his  hand  over  its 
stomach  so  that  it  shall  not  be  distended.  In  this  manner,  mucus  and 
fluid  in  the  upper  air  passages  are  forced  out  through  the  baby's  nose 
and  are  wiped  away  by  the  nurse  as  she  draws  the  gauze  along  and 
prepares  a  fresh  surface  for  another  "blow." 

In  addition  to  the  methods  above  mentioned,  a  catheter  or  other 
varieties  of  suction  apparatus  may  be  used  for  withdrawing  mucus  from 
the  upper  air  passages,  but  are  seldom  employed  by  the  author. 

Artificial  Respiration. — For  performing  artificial  respiration  various 
methods  are  in  common  use  and  all  have  their  place  at  times. 

Preparation. — One  important  fact  to  be  emphasized  in  this  connection 
is  that  in  every  labor  which  is  markedly  prolonged,  or  in  which  the  fetal 
heart  sounds  have  been  slowed,  and  in  every  operative  delivery,  the 
possibility  of  an  asphyxiated  baby  should  be  borne  in  mind  and  prepara- 
tions for  treating  it  be  made.  These  preparations  consist  chiefly  in  hav- 
ing at  hand  two  tubs,  one  containing  warm  water  at  a  temperature  of 
about  115°  F.,  the  other  containing  cold  water  with  ice  to  keep  it  cool. 

Until  the  reflexes  have  returned  in  the  baby  there  is  no  advantage 
in  trying  to  stimulate  its  respiration  by  cold  applications  to  its  skin  and 
there  is  a  distinct  disadvantage  in  the  danger  of  lowering  its  vitality. 
Hence  at  first  it  is  the  warm-water  tub  which  is  needed  and  it  is  the 
author's  custom  to  keep  the  baby  in  the  warm  water  as  much  as  possible 
while  performing  artificial  respiration  upon  it. 

If  the  baby  is  asphyxiated  at  birth  the  cord  is  tied  and  cut  at  a  sufli- 
cient  distance  from  its  abdomen  to  allow  of  a  second  ligature,  cutting 
and  sterile  dressing  after  the  procedures  of  resuscitation  are  over. 

With  the  upper  air  passages  cleared  as  already  described,  the  baby  is 

at  once  placed  in  the  tub  of  warm  water  with  its  face  supported  above 

the  level  of  the  water.     With  its  vitality  thus  protected  by  the  heat, 

artificial  respiration  may  be  carried  on  by  a  modification  of  Sylvester's 

23 


354      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

method  as  shown  in  Figs.  248  and  249.  With  the  arms  of  the  baby  between 
the  thumbs  and  forefingers  of  the  obstetrician,  while  the  back  of  the  thorax 
is  supported  by  his  remaining  fingers,  the  operator  Hfts  the  arms  and  thorax 
and  thus  expands  the  baby's  chest  (see  Fig.  248).  In  the  next  move- 
ment the  operator  transfers  his  forefingers  to  the  scapular  region  and 
compresses  the  baby's  chest  with  his  thumbs  (see  Fig.  249).  With  the 
alternation  of  these  two  movements,  10  to  18  per  minute,  artificial  respira- 
tion is  maintained  with  very  little  shock  to  the  baby  and  often  with  most 
gratifying  results.    As  soon  as  the  reflexes  return  and  the  baby  begins 


Fig.  248. — Modified  Sylvester's  method.      .Artificial  inspiration.      Baljy  in   tub  of 

warm  water. 


to  use  its  diaphragm,  respiration  may  be  stimulated  by  transferring  the 
baby  for  an  instant  to  the  tub  of  ice-water,  immediately  returning  it  to 
the  warm  water,  so  as  not  to  lower  its  vitality.  Dashing  a  few  drops  of 
the  ice-water  onto  the  chest  of  the  baby  while  it  is  still  in  the  warm  water 
will  often  suffice  to  stimulate  its  respiratory  movements.  As  a  rule  it  is 
well  to  keep  the  baby  in  the  warm  tub  with  occasional  short  transfers 
to  the  cold  tub  until  it  cries  well.  It  should  then  be  dried^  its  cord  tied 
again  at  the  usual  distance  from  the  body,  a  sterile  cord  dressing  applied, 
the  baby  wrapped  in  a  warm  blanket  and  placed  in  its  crib.     In  every 


ASPH  YXIA   XEONA  TOR  UM 


355 


case  of  asphyxia  the  baby  should  be  carefully  watched  after  resuscitation 
for  any  evidence  of  failing  respiration. 

The  method  just  described  is  the  one  usually  employed  by  the  author 
in  his  service  at  the  Sloane  Hospital  and  in  his  private  practice  and  the 
preparation  of  the  tubs  of  hot  and  cold  water  is  that  expected  of  his 
nurses.  In  some  cases  the  baby  does  not  respond  to  this  method  of  arti- 
ficial respiration  and  other  well-known  methods  should  be  tried,  per- 
haps returning  the  baby  at  intervals  to  the  warm  tub  and  the  modified 
Sylvester  method  just  described. 


Fig.  249. — Artificial  expiration.    Baby  in  tub  of  warm  water. 

A  good  method  is  the  Schidtze  method,  in  which  the  baby  is  held  with 
the  operator's  thumbs  over  the  thorax,  the  index-fingers  in  the  axillae 
and  the  remaining  fingers  over  the  scapular  region.  The  baby  is  first 
swung  do^\Ti  between  the  operator's  thighs,  the  operator  in  the  meantime 
lifting  forward  the  baby's  thorax  (see  Fig.  250).  This  evidently  expands 
the  baby's  chest.  In  the  next  movement  the  baby  is  gently  swung  over 
the  operator's  shoulder,  its  thorax  falling  on  the  thumbs  of  the  operator 
which  thus  compress  it  (see  Fig.  251). 

With  the  alternation  of  these  two  movements  artificial  respiration 
may  be  carried  on.    It  is  readily  seen,  however,  that  in  cases  of  fracture 


^oG      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

of  either  of  the  extremities  or  the  clavicle,  the  method  is  not  one  to  be 
recommended. 

A  substitute  for  the  Schultze  method  suggested  by  Byrd,  in  1870, 
modified  by  Dew,'  in  1893,  and  generally  known  as  Dew's  method,  is  de- 
picted in  Figs.  252,  253,  254,  and  255.  He  describes  the  method  as  follows: 
"  Grasp  the  infant  with  the  left  hand,  allowing  the  neck  to  rest  between 


Fig.  250. — Schultze  method. 
First  motion. 


Fig.  251. — Schultze  method. 
Second  motion. 


the  thumb  and  forefinger,  the  head  falling  far  over  backward  (see  Fig. 
252)  straightening  the  mouth  with  the  laryn.x  and  trachea,  thereby  serv- 
ing to  raise  and  hokl  open  the  epiglottis.  The  upper  portion  of  the  back 
and  scapulae  resthig  in  the  jjalm  of  the  hand,  the  other  three  fingers  are 

1  Establishing  a  New  Method  of  Artificial  Respiration  in  Asphyxia  Neonatorum,  New 
York  Medical  Record,  vol.  xliii,  No.  10,  pp.  289-292. 


ASPHYXIA  NEONATORUM 


35- 


inserted  in  the  axilla  of  the  baby's  left  arm,  raising  it  upward  and  out- 
ward.   Then  with  the  right  hand,  if  the  baby  is  large  and  heavy,  grasp 


Fig.  252.— Dew  method. 


Fig    253. — Dew  method. 


Fig.  254. — Dew  method. 


Fig.  255. — Dew  method. 


358      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

the  knees  in  such  a  way  as  to  hold  them  with  the  right  knee  resting 
between  the  thuml)  and  forefinger,  the  left  between  the  fore-  and  middle 
fingers.  This  position  will  allow  the  back  of  the  thighs  to  rest  in  the 
palm  of  the  operator's  hand.  If  tlie  infant  is  small  and  light  it  will  be 
found  more  convenient  and  easier  to  hold  it  in  the  same  way  by  the 
ankles  instead  of  the  knees,  allowing  the  calves  instead  of  the  thigh  to 
rest  in  the  palm  of  the  hand. 


Fig.  256. — Author's  method. 


"The  next  step  is  to  depress  the  pelvis  and  lower  extremities  so  as  to 
allow  the  abdominal  organs  to  drag  the  diaphragm  downward,  and  with 
the  left  hand  to  gently  bend  the  dorsal  region  of  the  spine  backward 
(see  Fig.  253).  This  enlarges  the  thoracic  cavity  and  produces  inspira- 
tion. Then,  to  excite  expiration,  reverse  the  movement,  bringing  the 
head,  shoulders  and  chest  forward,  closing  the  ribs  upon  each  other 
(see  Fig.  254).  At  the  same  moment  bring  forward  the  thighs,  resting 
them  upon  the  abdomen. 

"The  movement  arches  the  lumbar  region  backward  and  so  bends  the 


ASPHYXIA   NEONATORUM 


359 


(;hild  upon  itself  as  to  crowd  together  the  contents  of  the  thoracic  and 
abdominal  cavities,  bringing  about  a  most  complete  and  forcible 
expiration. 

"By  elevating  the  buttocks  and  depressing  the  head  and  shoulders 
(see  Fig.  255)  the  expulsion  of  mucus  can  be  affected,  as  in  the  Schultze 
method." 


Fig.  257. — Author's  method. 


A  method  often  used  by  the  author  in  alternation  with  the  modified 
Sylvester  method  in  the  warm  tub  is  that  shown  in  Figs.  256  and  257, 
in  which  the  baby  held  as  in  Fig.  256  is  rather  rapidly  changed  to  the 
position  of  Fig.  257,  then  returned  to  Fig.  256.  Inspiration  is  stimulated 
by  the  motion  from  256  to  257  in  two  ways:  (1)  By  the  reflex  stimula- 
tion of  rushing  through  the  air;  (2)  by  the  descent  of  the  liver  and  dia- 
phragm which  expands  the  chest  capacity.  The  results  of  this  method 
are  often  very  satisfactorv. 


360      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 


Reflex  Stimulation. — A  method  of  rcflexly  .stiinulating  respiration  is 
that  of  Lahorde,  wliich  consists  in  rhythmic  tractions  npon  the  tongue, 
either  with  a  forceps  or  the  fingers.  This  method  is  based  on  the  principle 
that  traction  on  the  tongue  refiexly  stimuhites  the  respiratory  centre 
and  the  phrenic  nerve. 

In  desperate  cases,  any  or  e\en  all  of  the  above  methods  may  be  used 
before  deciding  the  case  is  hopeless,  providing,  of  course,  the  fetal  heart 
is  still  beating.  The  author  has  several  times  succeeded  in  resuscitating 
apparently  hopeless  cases  by  direct  insufflation — the  mouth-to-mouth 
method — with  several  layers  of  gauze  placed  over  the  mouth  of  the 
baby  the  operator  gently  blows  into  the  baby's  mouth  at  regular  inter- 
vals, imitating  inspiration,  and  then  com- 
presses the  chest  with  his  hand.  Not  infre- 
quently the  color  of  the  baby  under  this 
method  will  assume  its  normal  condition  and 
■voluntary  respiratory  movements  begin. 

The  physician  should  never  despair  so 
long  as  the  heart  continues  to  beat,  even  if 
voluntary  respiration  does  not  begin  for  an 
hour. 

Occasionally,  in  cases  of  asphyxia  asso- 
ciated with  fracture  of  the  fetal  skull  and 
cerebral  hemorrhage,  benefit  is  obtained  by 
operation  with  the  removal  of  the  clot  and 
pressure.  Recovery  under  these  conditions, 
however,  is  exceptional. 

One  of  the  most  valuable  methods  of  re- 
suscitating asphyxiated  babies  is  by  the  use 
of  the  lungmotor  (see  Fig.  258)  which  in 
the  author's  experience  has  proved  both 
efficient  and  safe. 

The  lungmotor  consists  of  two  air  pumps 
which  operate  in  unison,  yet  are  not  connected 
in  any  way  as  far  as  the  interchange  of  air  is 
concerned.  At  no  time  does  the  devitalized 
air  come  in  contact  with  the  fresh  air  or 
oxygen.  It  works  by  hand — three  fingers. 
An  upward  movement  of  the  lungmotor  fills  "inspiration"  cylinder 
with  air  or  oxygen  or  a  mixture  of  both,  according  to  the  setting  of  the 
air  and  oxygen  valve.  At  the  same  time  the  "expiration"  cylinder  fills 
with  the  expired  air  expelled  by  the  lungs  of  the  subject.  Conversely 
the  following  downward  movement  of  the  handle  and  piston  forces  the 
air  and  oxygen  now  contained  in  the  "inspiration"  cylinder  into  the 
lungs  of  the  subject  and  discharges  the  expired  air  of  the  expiration 
cylinder  into  the  open. 

To  make  the  lungmotor  available  for  persons  of  all  ages  and  corre- 
spondingly varying  lung  capacities  the  lungmotor  is  provided  with  adjust- 
ments for  different  air  volumes  suitable  for  newborn,  five-year-old,  ten- 


FiG.  258. — The  lungmotor. 


IMMEDIATE  CARE  AFTER  BIRTH  OF  PREMATURE  BABIES     361 

year-old  children,  fifteen-year-old  or  small  adult,  adult  average  and  adult 
large.     This  range  provides  for  all  sizes  of  subject. 

The  volume  notches  for  size  of  subject  are  on  the  "inspiration"  piston 
rod  opposite  to  each  of  the  sizes  of  subject,  viz.:  Newborn,  five-year-old, 
ten-year-old  children,  fifteen-year-old  or  small  adult,  adult  average  and 
adult  large.  The  volume  notches  are  engaged  by  a  slide  pin  on  top  of 
the  "inspiration"  cylinder  cover.  The  slide  pin  can  be  swung  around 
the  circle  over  the  graduated  volume,  size  and  stroke  regulating  dial, 
the  graduations  with  plain  marks  for  corresponding  ages  registering  with 
the  notches  in  the  piston  rod. 

The  treatment  of  cases  of  asphyxia  neonatorum  often  has  associated 
with  it  most  grievous  disappointment.  Not  infrequently  the  obstetrician 
after  strenuous  efforts  will  have  his  hopes  raised  and  will  perhaps  believe 
he  has  succeeded  in  saving  the  child,  only  to  have  them  dashed  to  the 
ground  during  the  next  twenty-four  to  forty-eight  hours  by  the  death 
of  the  child  from  atelectasis.  On  the  other  hand  the  permanent  successes 
are  frequent  enough  to  reward  one  for  patient  persistent  eftorts. 

THE  IMMEDIATE  CARE  AFTER  BIRTH  OF  PREMATURE  BABIES  OR 
BABIES  OF  UNDERSIZE  OR  UNDERWEIGHT. 

One  of  the  great  problems  in  the  care  of  premature  babies  is  the  main- 
tenance of  their  body  heat.  The  author's  experience  at  the  Sloane  Hos- 
pital leads  him  to  believe  that  while  a  baby  weighing  4|  pounds  or  over 
will  usually  do  w^ell  at  the  ordinary  temperature  of  the  nursery,  a  baby 
weighing  less  than  this  does  much  better  in  a  temperature  of  85°  to  90°  F. 
For  this  reason  it  is  his  custom  at  the  Sloane  Hospital  to  place,  for  a  time 
at  least,  a  baby  weighing  4^  pounds  or  less  in  an  incubator  in  which 
the  temperature  is  maintained  at  first  around  90°  F.  and  then  gradually 
reduced  as  the  baby  shows  that  it  can  maintain  its  body  heat  at  a  lower 
incubator  temperature.  In  order  to  preserve  the  vitality  of  these  prema- 
ture babies,  as  soon  as  possible  after  birth  they  are  anointed  with  steril- 
ized petrolatum  to  remove  the  vernix;  a  cord  dressing  is  applied;  they 
are  wrapped  in  a  warm  blanket  and  then  transferred  at  once  to  the 
incubator  w^here  the  incubator  clothing  is  put  on.  The  clothing  of  the 
baby  while  in  the  incubator  does  not  need  to  be  as  much  or  as  heavy  as 
that  of  the  baby  in  the  nursery  and  the  author's  experience  has  led  him 
to  adopt  as  suitable  clothing  for  an  incubator  baby  the  following:  One 
short  flannel  shirt  and  two  napkins.  One  of  the  napkins  is  folded  diag- 
onals^, brought  between  the  thighs  and  pinned  in  the  usual  way.  The 
other  napkin  is  folded  lengthwise  about  the  waist  and  thighs  of  the  baby 
and  pinned  with  the  bottom  turned  up  if  desired.  A  small  square  of 
canton  flannel  is  usually  placed  inside  the  inner  napkin  next  to  the  anus 
to  receive  the  baby's  stools.  This  light,  loose  clothing  allows  freedom  of 
motion  to  the  baby  and  is  heavy  enough  for  the  warm  atmosphere  in 
which  it  is.  The  baby  in  the  incubator  is  handled  as  little  as  possible  in 
changing  its  diapers,  it  is  not  bathed  and  it  is  weighed  only  at  intervals 
of  several  days.     Its  feeding  is  discussed  in  the  chapter  on  Lactation, 


3G2      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

see  page  408.  Suffice  it  to  say  here  that  an  incubator  baby  usually  needs 
human  breast  milk  and  usually  does  best  when  fed  in  small  amounts 
with  halt'-streniith  milk  at  shorter  intervals  than  a  full-term  baby  is  fed. 

Incubators  and  Their  Substitutes.  —  To  the  ditierent  \arieties  of 
incubators  which  have  been  in  use  for  many  years,  most  of  which  have 
consisted  of  an  air  chamber  warmed  by  a  tank  of  water  heated  by  a  gas 
or  other  burner,  there  have  been  three  common  objections: 

Insufficient  air  space. 

Insufficient  circulation  of  air. 

Difficulty  in  maintenance  of  a  constant  temperature. 


11,  PILOT  LIGHT 


Fig.  259. — Infant  incubator. 


Impressed  with  these  objections  the  author  has  sought  to  overcome 
them  by: 

1.  Having  an  incubator  built  several  times  larger  than  those  in  com- 
mon use. 

2.  IMaintaining  a  gentle  current  of  filtered  air  through  it,  the  air  enter- 
ing through  a  gauze-screened  opening  below  and  being  sucked  out  by  a 
small  electric  fan  above. 

3.  Maintaining  a  constant  temperature  by  different  series  of  electric 
lights  which  may  be  turned  on  or  off  at  will.  This  incubator  (see  Fig. 
259)  has  been  in  use,  with  two  of  its  fellows,  at  the  Sloane  Hospital  for 
two  years  and  has  clearly  demonstrated  its  superiority  over  the  incuba- 
tors of  the  old  t^-pe.  Babies  of  greater  prematurity  and  lesser  weight  have 
lived  and  developed  in  these  incubators  than  any  we  have  been  able  to 
save  heretofore. 

The  mechanical  description  of  the  incubator  is  as  follows:  It  is  built 
entirely  of  steel  finished  on  the  outside  in  aluminum  bronze  and  painted 


IMMEDIATE  CARE  AFTER  BIRTH  OF  PREMATURE  BABIES     363 

on  the  inside  with  gray  enamel.  It  consists  primarily  of  the  incubator 
proper  which  is  84|  inches  in  length,  46|  inches  in  height,  and  30|  inches 
in  depth.  It  is  supported  on  legs  30  inches  high,  making  the  total  height 
76|  inches.  In  front  (see  Fig.  259)  at  each  side  are  two  double  doors  of 
beveled  plate  glass  set  in  nickel-plated  brass  frames.  At  each  end  is  a 
beveled  plate  glass  window  24j  inches  by  20^  inches.  In  the  interior 
directly  behind  each  set  of  doors  is  a  basket  or  cradle,  built  of  nickel- 
plated  brass  wire  and  supported  on  hooks,  in  which  the  infant  lies. 
Beneath  each  cradle  is  a  tray  which  contains  water  for  keeping  the  air 
moist.  The  condition  of  the  air  is  indicated  by  a  hygrometer  and  its 
temperature  by  a  thermometer,  both  of  which  are  visible  through  the 


Fig.  260. — Incubator  heated  by  a  gas  burner  or  an  alcohol  lamp. 

glass  doors.  Beneath  each  tray  is  a  series  of  violet-colored  incandescent 
lamps  which  furnish  the  heat  which  is  distributed  by  means  of  a  heat 
disbursor.  On  the  roof  of  the  incubator  a  small  motor  with  a  fan  and 
the  necessary  resistance  is  enclosed  in  a  metal  chimney  leading  from  the 
interior.  The  motor  is  controlled  by  a  rheostat  situated  outside  of  the 
incubator  between  the  two  front  windows.  The  lamps  are  connected  in 
series  of  two  on  each  side  controlled  by  snap  switches  as  shown,  which  in 
turn  are  connected  with  the  house  current.  Directly  inside  of  each  door 
is  a  small  pilot  lamp.  When  the  incubator  is  in  operation  the  air  enters 
through  the  intakes  (No.  6),  comes  in  contact  with  the  heat-disbursing 
plates  and  passes  throughout  the  interior.  By  means  of  the  motor  fan 
a  continual  gentle  current  of  fresh,  warm  air  is  kept  circulating  through 


364      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

the  incubator.    The  degree  of  heat  is  regulated  by  turning  on  more  or  less 
of  the  snap  switches  and  by  ])r(>per  regulation  of  the  motor. 


Fig.  261. — Cotton  jacket  and  socks. 


Fig.  262. — Baby  in  cotton  jacket  and  socks. 


CAPUT  SUCCEDANEUM  AND  CEPHALHEMATOMA  365 

Where  the  house  is  not  wired  for  electricity  an  incubator  of  the  old 
type  (see  Fig.  260),  in  which  the  water  tank  surrounding  the  air  chamber 
is  heated  by  a  gas  burner  or  an  alcohol  lamp  may  be  used.  The  objec- 
tions of  limited  air  space  and  poor  circulation  of  air  must  be  recognized, 
however,  and  overcome  as  far  as  possible. 

Substitutes  for  Incubators. — In  private  families  where  it  is  impossible 
to  secure  an  incubator  it  is  often  possible  by  different  makeshifts  to 
obtain  admirable  results  without  it.  In  some  houses  a  small  room 
may  be  chosen  and  by  the  regular  heating  apparatus  of  the  house  the 
temperature  may  be  raised  and  maintained  at  or  above  80  degrees. 

The  author  has  at  times  obtained  good  results  by  surrounding  the 
baby's  crib  with  folding  screens  over  which  blankets  are  thrown,  the 
temperature  of  this  space  being  maintained  by  an  electric  heater. 

In  all  of  these  arrangements  of  enclosed,  heated  air  spaces,  the  impor- 
tance of  ventilation  from  a  nearby  window  should  be  borne  in  mind. 

When  a  baby  is  taken  out  of  the  incubator,  which  is  done  for  a  little 
while  at  a  time,  after  the  temperature  of  the  incubator  has  been  gradually 
reduced  to  approximately  that  of  the  nursery,  it  is  an  excellent  plan  to 
dress  the  baby  something  after  the  manner  of  the  Esquimaux,  i.  e.,  in 
what  is  called  at  the  Sloane  Hospital  a  cotton  jacket  and  socks  (see  Figs. 
261  and  262)  which  are  easily  made  by  stitching  a  layer  of  cotton  to  a 
gauze  backing  of  the  shape  shown.  These  are  made  in  a  few  moments  by 
the  nurse  and  are  very  useful  in  maintaining  the  baby's  body  heat.  If  in 
this  cotton  jacket  the  baby's  temperature  tends  to  remain  subnormal, 
additional  heat  can  be  supplied  by  an  electric  pad  or  by  hot-water  bags, 
great  care  being  taken  not  to  burn  the  baby. 

In  many  cases  even  without  an  incubator  or  a  superheated  room  a 
good  result  may  be  obtained,  in  a  baby  not  too  premature,  by  the  use 
of  the  cotton  jacket  and  an  electric  pad. 

CAPUT    SUCCEDANEUM   AND   CEPHALHEMATOMA. 

Caput  Succedaneum. — After  a  long  labor  the  child's  head  usually 
presents  a  swelling  over  the  area  which  has  been  surrounded  first  by  the 
cervical  ring  and  later  by  the  vaginal  canal  and  vulvar  orifice.  This 
swelling  is  called  the  caput  succedaneum  and  varies  in  its  location  on  the 
head  according  to  the  presentation  and  position  of  the  fetus.  Thus  in 
an  occipito-anterior  position  of  the  vertex  it  is  usually  found  over  the 
right  parietal  bone  if  the  position  was  an  L.  O.  A.,  and  over  the  left 
parietal  bone  if  it  was  an  R.  O.  A.  The  condition  consists  of  an  edema 
of  the  scalp  and  is  caused  by  absence  of  pressure  on  the  head  over  the 
area  corresponding  to  the  opening  in  the  birth  canal,  while  the  walls  of 
the  parturient  canal  firmly  compress  the  rest  of  the  head.  It  naturally 
follows  that  the  longer  and  more  difficult  the  labor  is,  the  greater  will  be 
the  edema  of  the  exposed  portion  of  the  scalp  and  the  size  of  the  caput 
succedaneum.  On  the  other  hand,  if  the  labor  has  been  rapid  and  easy 
the  caput  succedaneum  may  be  absent.  If  on  account  of  the  long  tedious 
labor  there  has  been  a  marked  molding  of  the  fetal  head,  this  molding, 


366      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

together  with  the  caput,  may  cause  a  disfigurement  of  the  child  at  birth 
which  may  be  alarming  to  the  parents  and  friends.  They  may  be 
assured,  howe^•e^,  that  this  disfigurement  is  only  temporary  and  that  in 
from  twent\-four  to  fort>-eight  hours  it  will  largely  have  disai)peared. 
It  needs  no  treatment  save  cleanliness  of  the  scalp  to  avoid  infection  in 
case  there  has  been  an  abrasion  of  the  scalp  during  the  delivery. 

Cephalhematoma. — Another  swelling  which  may  appear  on  the  child's 
head  during  the  first  week  after  birth  is  that  of  a  cephalhematoma.  It 
differs  from  the  caput  succedaneum  just  described  in  ninnerous  particu- 
lars. While  the  caput  is  present  and  most  marked  at  l)irth  and  rapidly 
disappears,  the  cephalhematoma  as  a  rule  does  not  appear  until  several 


Fig.  263. — Single  cephalhematoma. 


days  after  birth  and  then  usually  increases  for  several  days.  The  cephal- 
hematoma consists  of  an  effusion  of  blood  beneath  the  pericranium  and 
is  therefore  limited  in  extent  by  the  sutures  surrounding  each  cranial 
bone.  The  caput  succedaneum,  on  the  other  hand,  involving  only  the 
tissues  of  the  scalp,  may  extend  right  over  the  sutures  and  fontanelles. 
The  cephalhematoma  is  caused  by  the  rupture  of  a  vessel  between  the 
pericranium  and  one  of  the  cranial  bones  which  has  received  less  support- 
ing pressure  during  the  labor  than  the  rest  of  the  fetal  head.  It  is  there- 
fore due  to  relative  absence  of  pressure  over  this  area  rather  than  to  an 
excess  of  pressure.  The  cephalhematoma  may  follow  a  breech  delivery 
as  well  as  a  vertex,  although  more  common  in  the  latter.  It  may  be 
single,  as  shown  in  Fig.  26-3  or  double,  as  seen  in  Fig.  264.    ^Yhile  more 


CAPUT  SUCCEDANEUM  AND  CEPHALHEMATOMA 


367 


common  over  one  of  the  parietal  bones,  it  may  occur  over  the  occipital 
or  one  of  the  frontals. 

Clinical  Course. — As  stated  above,  the  cephalliematoma  usually  first 
appears  several  clays  after  the  birth  of  the  child.  It  generally  increases  in 
size  for  several  days,  remains  stationary  for  a  "^'eek  or  more  and  then, 
as  a  rule,  gradually  disappears.  Unless  there  has  been  an  abrasion  of  the 
scalp  over  the  tumor  it  does  not  often  become  infected  and  the  anxiety 
of  the  family  can  be  quieted  by  the  assurance  that  the  swelling  is  only 
temporary  and  that  it  will  probably  have  disappeared  in  from  six  to 
eight  weeks.  In  the  process  of  absorption  of  the  effused  blood  and  return 
of  the  pericranium  to  the  bone  a  hard  ridge  of  bony  spicules  can  often 


Fig.  264. — Double  cephalhematoma. 


be  felt  around  the  circumference  of  the  cephalhematoma.  As  the  fingers 
pass  from  the  surrounding  area  onto  this  elevated  ridge  and  then  down 
on  to  the  skull  nearer  the  centre  of  the  cephalhematoma  the  feel  of  a 
depressed  fracture  of  the  skull  is  suggested.  If  it  is  remembered  that  in 
the  process  of  repair  of  a  cephalhematoma  and  the  reattachment  of  the 
pericranium  to  the  skull  this  elevated  ridge  of  new  bone  projection  is  the 
rule,  the  diagnosis  is  usually  easy.  Furthermore,  the  time  elapsed  since 
the  birth  of  the  child  and  the  absence  perhaps  of  any  possible  trauma 
during  the  labor  should  aid  in  the  exclusion  of  fracture. 

Treatment. — As  the  rule  is  that  a  cephalhematoma,  provided  it  is  not 
infected,  will  absorb  without  treatment,  the  principle  of  treatment 
consists  of  protection  and  cleanliness.    If  any  abrasion  of  the  scalp  exists 


368      CARE  OF  CHILD  IN  ABNORMAL  CONDITION  AT  BIRTH 

near  tlie  cephalhematoma,  it  is  well  to  disinfect  this  abrasion  with  tinc- 
ture of  iodin  and  then  to  j^rotect  tiic  swelling  with  a  dressing  of  sterile 
gauze  in  order  to  avoid  any  further  abrasion.  It  is  often  desirable  to 
surround  the  swelling  with  a  ring  of  gauze  to  prevent  friction  from  the 
pillow.  The  question  occasionally  arises  in  the  case  of  a  large  cephal- 
hematoma: Will  the  i)rocess  of  absorption  not  be  hastened  by  aspira- 
tion and  the  withdrawal  of  the  fluid  portion  of  the  eft'used  l)lood?  The 
author  believes  that  this  is  not  to  be  recommended,  as  there  is  always 
more  or  less  risk  of  infection  in  this  procedure,  and  the  avoidance  of  infec- 
tion of  the  effused  blood  is  the  object  especially  desired. 

If  infection  of  the  cephalhematoma  has  occurred  it  should  be  treated 
on  general  surgical  principles  of  opening  and  drainage. 


CHAPTER  XI. 

THE  PUERPERIU:\I  AND   ITS  :\L\XAGE:MEXT. 

The  piierperium  is  the  term  applied  to  that  period  immediately 
following  the  birth  of  the  child  which  is  required  for  the  return  of  the 
uterus  and  parturient  canal  to  its  normal  condition.  The  time  usually 
required  is  about  six  weeks,  but  this  varies  greatly  with  the  muscle  and 
nerve  tone  of  the  individual.  In  some  of  the  healthy  women  of  the  labor- 
ing class  the  involution  of  the  uterus  is  often  as  well  advanced  at  two 
weeks  as  in  some  in  the  so-called  higher  walks  of  life  at  four  weeks. 

ANATOMICAL   AND   PHYSIOLOGICAL   CHANGES. 

The  Uterus. — At  the  end  of  pregnancy  the  uterus  measures  approxi- 
mately 12  inches  by  9  inches  by  8|  inches.  It  weighs  about  two  pounds 
and  has  a  capacity  of  about  400  cubic  inches. 

At  the  end  of  the  puerperium  it  measures  approximately  3  inches  by  2 
inches  by  1  inch,  weighs  about  Ij  ounces,  and  has  a  capacity  of  about  1 
cubic  inch. 

This  rapid  decrease  in  size,  called  involution  of  the  uterus,  is  well 
illustrated  by  Fig.  265,  which  is  a  photograph  of  a  uterus  taken  from  a 
woman  who  died  of  pneumonia  on  the  day  of  her  delivery.  Although 
not  regaining  its  normal  size  until  about  six  weeks  after  labor,  the  marked 
reduction  occurring  within  the  first  few  hours  of  the  puerperium  is  very 
striking.  The  distinction  between  the  upper  and  lower  uterine  segments 
is  well  marked.  The  bloodvessels  are  constricted  by  the  contraction 
and  retraction  of  the  muscular  fibers,  thus  making  the  upper  uterine  seg- 
ment, although  thick,  appear  firm  and  rather  anemic.  A  good  idea  of 
the  vascular  channels  of  the  pregnant  uterus  can  be  obtained  by  inject- 
ing a  cadaver  soon  after  delivery  with  formalin  and  then  making  a  frozen 
section  of  the  uterus,  as  was  done  in  Fig.  266.  From  this  it  is  seen  that 
the  uterus  is  riddled  with  vascular  channels  which  are  closed  by  the  con- 
traction and  retraction  of  the  uterus  indicated  in  the  preceding  figure. 

As  time  goes  on  the  muscular  fibers  atrophy  and  the  uterus  decreases 
rapidly  in  size  so  that  by  the  tenth  day  of  a  normal  puerperimn  it  has 
returned  to  the  true  pelvis  and  can  no  longer  be  felt  above  the  pubis. 

The  Endometrium. — The  separation  of  the  placenta  and  membranes 
from  the  uterus  taking  place  in  the  deeper  portion  of  the  spongy  layer  of 
the  decidua,  there  remains  lining  the  uterus  at  the  completion  of  the 
third  stage  of  a  labor  more  or  less  of  this  spongy  decidua  which  has  an 
irregidar  surface  infiltrated  with  blood.  At  the  placental  site  the  decidual 
surface  is  more  jagged,  is  raised  abo^'e  the  rest  of  the  uterine  cavity,  and 
24  "  (369) 


370 


THE  PUERPERIUM  AXD  ITS   MANAGEMENT 


the  blood  infiltration  is  greater.  The  superficial  part  of  the  decidual 
layer  undergoes  necrosis  and  is  cast  off  in  the  lochia  while  the  deeper 
portion  is  preserved,  becomes  transformed  into  connecti\'e  tissue  from 
which,  together  with  the  fundi  of  the  utricular  glands  which  are  left,  a 
new  endometrium  is  constructed. 

The  Cervix. — Immediately  after  delivery  the  cervix  is  widely  dilatable, 
admitting  even  the  cone-shaped  hand.  It  is  usually  more  or  less  lacerated 
and  shades  off"  into  the  vagina  in  such  a  Avay  as  to  make  its  anatomical 


Fig.  265. — Uterus  of  woman  who  died  on  the  day  of  her  delivery. 

outlines  indistinct.  The  lips  of  the  cervix  are  edematous  and  at  the 
close  of  labor  are  often  visible  at  the  vuhar  orifice.  On  the  second  day 
the  cervix  has  reestablished  its  anatomical  landmarks,  although  the 
internal  os  usually  admits  the  finger  at  the  end  of  a  week  and  the  external 
OS  always  remains  more  patulous  than  in  a  nullipara. 

The  Vulva. — On  the  day  following  delivery  the  \ulva  is  still  edematous 
and  tender  and  may  be  a  source  of  discomfort  to  the  patient.  This  swell- 
ing and  tenderness  rapidly  disappears,  however,  without  treatment  and 


ANATOMICAL  AND  PHYSIOLOGICAL  CHANGES 


371 


is  seldom  mentioned  by  the  patient  after  the  third  day.  The  lacerations, 
if  repaired  under  aseptic  precautions,  usually  unite  readily  and  are  repre- 
sented later  simply  by  whitish  cicatrices. 

The  Vagina. — The  vagina  after  labor  is  patulous  with  relaxation 
of  both  anterior  and  posterior  walls.  The  tone  rapidly  returns  to  this 
canal,  although  it  remains  a  little  more  patulous  than  in  a  nullipara  and 
the  nigse  are  a  little  less  distinct. 

After-pains. — In  the  first  labor  "after-pains"  or  painful  contractions 
of  the  uterus  after  the  expulsion  of  the  placenta  are  unusual.     These 


Fig.  266. — Frozen  section,  showing  vessels  of  puerperal  uterus 


after-pains  are  usually  due  to  the  accumulation  of  small  blood-clots  in 
the  uterine  cavity  on  account  of  imperfect  contraction.  They  are  com- 
mon in  multiparge  and  often  increase  with  each  labor,  as  each  labor  seems 
to  diminish  the  power  of  the  uterus  to  contract  and  remain  contracted 
as  it  does  in  the  first. 

It  is  especially  seen  in  labors  where  the  uterus  has  been  overdistended, 
as  in  hydramnios,  multiple  preg^iancy,  or  in  very  tedious  labors  where 
the  uterine  muscle  has  become  tired  out. 

It  is  always  wise  for  the  obstetrician  to  provide  for  the  relief  of  these 
pains  before  he  leaves  the  house  of  the  patient,  otherwise  he  is  very  apt 


372 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


to  be  disturbed  during  the  night  by  a  request  for  such  reHef.  A  tablet 
of  codien,  gr.  ss,  repeated  in  two  hours  usually  serv^es  this  purpose  well. 

Where  the  pains  are  persistent,  the  use  of  the  ice-bag  o\'er  the  fundus 
uteri  often  gives  marked  relief  and  maintains  the  contraction  of  the 
uterus. 

Occasionally  the  uterus  will  be  found  to  be  ballooned  with  blood-clots 
and  the  patient  be  suffering  intensely  with  after-pains.  In  such  cases 
if  compression  of  the  fundus  does  not  empty  the  uterus  it  is  sometimes 
advisable  in  extreme  cases  to  give  a  hot  intra-uterine  douche,  or  even  to 
clean  out  the  clots  Mith  the  sterile  hand,  then  administer  a  dose  of  ergot 
and  apply  the  ice-bag  to  the  fundus. 


Fig.  267. — Lochia,  first  day. 


The  Lochia. — For  two  or  three  weeks  after  deli\ery  there  occurs  a 
discharge  from  the  uterovaginal  canal  which  is  called  the  lochia.  For 
the  first  three  or  four  days  the  discharge  is  composed  chiefly  of  blood 
mixed  with  decidual  cells  and  epitheliiun  from  the  cervix  and  vagina. 
It  looks  bloody  and  is  called  the  lochia  mhra.  It  is  alkaline  in  reaction 
and  has  the  odor  of  blood  or  fresh  meat.  The  sources  of  the  blood  are 
the  large  sinuses  of  the  placental  site,  the  torn  vessels  of  the  decidua,  and 
the  various  tears  in  the  cervix,  vagina  or  vulva. 

For  the  next  three  or  four  days  the  discharge  is  lighter  in  color  and 
serous  in  character  and  is  called  the  lochia  serosa. 

The  disintegration  and  casting  off  from  the  uterine  ca\'it\'  of  any 
remains  of  decidua  and  the  granulation  of  lesions  in  the  parturient  canal 


\n.rouicAL  Ann  PnyswwoiCAL  changes 


37J 


Fig.  268.-Lochia.  third  day. 


Fig.  269.— Lochia,  tenth  day 


374  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

now  give  to  the  lochia  a  whiter  color,  so  that  from  about  the  se\'euth  to 
the  fourteenth  day,  perhaps  longer,  it  is  called  the  lochia  alba. 

In  some  cases  the  lochia  rubra  or  bloody  lochia  ])crsists  for  several 
weeks.  This  is  usually  the  result  of  improj)er  involution  of  the  uterus 
which  may  arise  from  lack  of  nursing,  from  retained  secundines,  the 
presence  of  fibroid  tumors,  posterior  displacement  of  the  uterus,  etc. 

It  is  more  apt  to  be  prolonged  in  multipara^  than  in  primipane.  The 
microscopic  appearance  of  the  lochia  on  the  first,  third  and  tenth,  days 
may  be  seen  in  Figs.  267,  208,  and  2()9. 

Odor. — It  has  already  been  stated  that  the  odor  of  the  lochia  during 
the  first  three  or  four  days  resembles  that  of  blood  or  fresh  meat.  After 
these  first  few  days,  as  the  mucus  of  the  canal  forms  a  larger  proportion 
of  the  discharge,  the  lochia  has  a  peculiar  odor  of  its  own  which  every 
obstetrician  should  become  familiar  with  in  order  to  recognize  any  depar- 
ture from  the  normal.  The  odor  of  the  normal  lochia  at  this  time  always 
reminds  the  author  of  smoked  ham.  It  is  altogether  different  from  the 
otl'ensive  odor  which  the  lochia  sometimes  assumes  when  more  than  the 
normal  amount  of  organic  material  is  retained  in  the  birth  canal  and  this 
organic  material  has  been  invaded  with  putrefactive  bacteria. 

Bacteria. — Thanks  to  the  labors  of  Doderlein,  Kronig,  ^Nlenge,  and 
Williams,  it  is  now  established  that  during  the  first  few  days  of  the  puer- 
perium  the  normal,  uninfected  uterine  cavity  does  not  contain  bacteria. 

After  the  first  few  da^■s  bacteria  are  found  there  but  in  the  normal 
condition  they  are  not  of  the  pyogenic  varieties.  ^Moreover,  the  vaginal 
discharge  during  the  normal  puerperium,  although  containing  numerous 
harmless  bacteria,  does  not  contain  p\ogenic  organisms,  with  the  excep- 
tion of  gonococci,  which  may  have  been  present  before  or  during  preg- 
nancy. The  reaction  of  the  vagina  during  pregnancy  is  acid  but  during 
the  puerperium  is  alkaline. 

Amount. — The  quantity  of  lochia  varies  greatly  in  different  women. 
In  general  the  amount  is  greater  if  the  woman  does  not  nurse  her  child 
and  the  resulting  stimulation  of  uterine  contractions  is  absent. 

The  amount  has  been  estimated  as  follows:  During  the  first  four 
days  1  kilogram,  or  2|  pounds,  during  the  next  two  days  270  grams,  or 
9  ounces,  during  the  next  three  days  200  grams,  or  7  ounces.  The  whole 
amount  being  about  85  pounds.  This  estimation,  however,  is  of  very 
little  practical  value  and  the  frequency'  of  change  of  vulvar  pads  needed 
and  their  normal  appearance  is  of  much  greater  importance  to  the 
obstetrician. 

The  normal  amount  of  lochia  should  not  require  change  of  vulvar  pads 
oftener  than  every  four  hours.  The  appearance  of  the  pads  on  the 
first,  third  and  tenth  days  is  shown  in  Figs.  270,  271,  and  272. 

A  marked  diminution  in  the  amount  of  the  lochia,  and  especially  an 
absence  of  lochia  before  the  proper  time,  should  be  looked  upon  with 
suspicion  as  being  suggestive  either  of  retention  or  infection. 

Perspiration. — During  the  first  week  of  the  puerperium  this  function 
of  the  skin  is  greatly  increased  and  for  a  woman  at  this  time,  especially 
after  sleeping,  to  find  herself  bathed  in  perspiration  is  a  very  common 


ANATOMICAL  AND  PHYSIOLOGICAL  CHANGES  375 

picture.  It  seems  to  be  one  of  nature's  ways  for  eliminating  waste  pro- 
ducts in  the  process  of  general  involution  incident  to  the  puerperium. 
It  has  an  important  clinical  bearing  in  the  fact  that  a  woman  with  dress 
wet  with  perspiration  is  more  subject  to  chilling  and  colds  when  exposed 


Fig.  270. — Vulva  pad,  first  day. 

to  draughts,  and  the  chilling  of  the  breasts  may  cause  or  increase  the 
congestion  of  them. 

Diet. — Regarding  the  diet  of  the  patient  following  her  delivery  opinions 
differ  somewhat  from  those  formerly  held,  and  the  idea  that  a  woman 
should  be  kept  upon  a  very  light  and  purely  fluid  diet  for  several  days 


Fig.  271. — Vulva  pad,  third  day. 

after  her  confinement  is  rapidly  losing  ground.  Aside  from  milk,  broths 
and  gruels,  the  author  is  accustomed  to  allow  eggs  and  toast  even  during 
the  first  twenty-four  hours  of  the  puerperium.  Weak  tea  and  coffee 
are  allowable,  if  the  patient  is  accustomed  to  them,  but  cocoa  once  or 
twice  a  day  is  preferable  as  tending  to  stimulate  the  secretion  of  the 


Fig.  272. — Vulva  pad,  tenth  day. 

milk.    A  gruel  made  from  corn  meal  is  also  of  value  in  stimulating  milk 
secretion. 

The  Bowels. — During  the  first  twenty-four  to  forty-eight  hours  of 
the  puerperium  there  is  usually  little  tendency  toward  a  normal  evacua- 


376  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

tion  of  the  bowels,  and  for  several  reasons.  They  have  usually  been 
thoroughly  evacuated  during  the  labor;  but  little  nourishment  is  taken 
during  this  period  and  on  account  of  the  sudden  decrease  in  intra-abdomi- 
nal pressure  it  requires  quite  a  little  time  for  the  intestines  to  adjust 
themselves  to  the  greater  abdominal  room  and  renew  normal  peristalsis. 

They  should  not  be  allowed  to  go  unmoved  longer  than  forty-eight 
hours,  except  perhaps  in  cases  of  complete  laceration  of  the  sphincter, 
and  if  the  patient  suffers  with  tympanites  she  may  be  relieved  by  an 
enema  at  any  time. 

On  the  third  day,  i.  e.,  at  the  end  of  about  forty-eight  hours,  it  is  well 
to  move  the  bowels  thoroughly  with  a  saline,  and  for  this  purpose  it  is 
the  author's  custom  to  administer  from  one-half  to  one  bottle  of  the 
liquor  magnesii  citratis.  This  is  agreeable  to  most  patients  and,  especially 
if  followed  by  an  enema,  is  usually  effectual  both  in  emptying  the  bowel 
and  also  in  relieving  the  breasts  which  are  apt  to  be  congested  at  this 
time. 

The  Bladder. — Even  if  the  perineum  has  been  sutured  it  is  wiser 
to  let  the  patient  urinate  voluntarily,  if  she  can,  rather  than  to  use  the 
catheter. 

It  is  so  easy  to  start  a  cystitis  by  the  use  of  the  catheter,  even  if  great 
care  is  observed,  that  the  author  always  prefers  to  avoid  the  catheter 
if  possible.  If  the  perineal  wound  is  gently  irrigated  with  some  weak 
antiseptic  solution  like  bichloride  (1  to  5000)  after  each  urination  no  harm 
seems  to  result  from  the  flow  of  the  urine  over  it.  It  must  be  borne  in 
mind,  however,  that  many  women  secrete  urine  very  rapidly  after  con- 
finement and  that  on  account  of  the  swelling  of  the  urethra  many  are 
unable  to  void  it.  For  these  reasons  it  is  well  to  instruct  the  nurse  to 
catheterize  the  patient  every  eight  hours  if  she  is  unable  to  empty  her 
bladder  voluntarily.  For  this  purpose  the  freshly  boiled  glass  catheter 
is  usually  preferable  to  the  soft  rubber  and  should  be  introduced  by  sight, 
not  by  touch,  i.  e.,  after  disinfecting  the  hands  the  labia  should  be  well 
separated  and  held  apart  by  the  fingers  of  the  one  hand,  the  vestibule 
thoroughly  cleansed,  and  the  catheter  passed  directly  into  the  meatus 
without  touching  the  labia.  In  some  women  the  secretion  of  urine  is  so 
rapid  that  the  catheter  has  to  be  used  every  six  hours  for  a  time,  both 
for  the  comfort  of  the  patient  and  to  prevent  the  distention  of  the  bladder 
interfering  with  the  contraction  of  the  uterus. 

Nursing. — Until  the  secretion  of  milk  is  established  in  the  breasts 
which  is  usually  on  the  third  day,  sometimes  on  the  second  in  multip- 
arse,  the  baby  should  be  put  to  the  breasts  only  infrequently. 

The  author's  custom  is  to  have  the  baby  put  to  the  breast  as  soon  as 
the  mother  has  had  a  rest  and  to  repeat  this  every  four  hours  during  the 
da>time,  but  not  at  night  until  the  secretion  of  milk  is  established. 

During  this  period  the  baby  should  not  remain  at  the  breast  longer 
than  five  minutes  at  a  time,  for  if  allowed  to  remain  longer  the  nipple 
is  very  apt  to  be  made  tender  and  perhaps  becomes  abraded.  That  it 
should  be  put  to  the  breasts  during  the  colostrum  period,  however,  is 
important  for  several  reasons. 


VISITS  OF  THE  OBSTETRICIAN  377 

1.  It  stimulates  the  contraction  of  the  uterus  which  is  much  needed 
at  this  time. 

2.  The  colostrum  serves  as  a  laxative  for  the  baby  and  aids  in  emptying 
its  intestines  of  meconium  in  preparation  for  the  milk  which  is  soon  to 
be  secreted. 

3.  The  nursing  of  the  baby  upon  the  breasts  tends  to  stimulate  their 
function  and  hastens  the  milk  secretion. 

On  the  occasion  of  the  next  visit  of  the  obstetrician  he  should  note  the 
height  of  the  fundus,  the  amount  of  the  lochia,  the  temperature  and  pulse 
of  the  mother  and  w^hether  she  has  been  able  to  urinate  or  not. 

The  condition  of  the  baby  should  also  be  noted :  its  color,  its  tempera- 
ture, whether  it  has  taken  hold  of  the  nipple  well,  whether  it  has  urinated 
or  not,  and  whether  its  bowels  have  moved. 

Visits  of  the  Obstetrician. — The  number  of  calls  the  obstetrician  should 
make  upon  his  patient  depends  of  course  upon  many  different  circum- 
stances— the  distance  of  the  patient  from  the  physician,  the  smoothness 
of  her  convalescence,  the  condition  of  the  baby,  etc.  The  author  can 
give  no  better  rule  than  to  mention  his  custom  in  the  care  of  an  obstetric 
case  in  a  large  city  like  New  York  which  is  as  follows: 

Two  visits  for  the  first  one  or  tw^o  days;  then  one  visit  a  day  until  the 
end  of  the  second  w^eek,  followed  by  a  visit  every  other  day  until  the  four 
weeks  have  expired.  The  question  naturally  arises  as  to  how  long  an 
obstetrician  should  remain  in  charge  of  the  case.  This  depends  upon 
whether  he  is  the  general  family  practitioner  who  has  attended  the  woman 
in  confinement  as  he  would  attend  her  through  an  attack  of  pneumonia, 
or  whether  he  is  recognized  as  an  obstetrician,  a  specialist  to  whom 
obstetric  cases  are  referred  and  who  devotes  special  time  and  study  to 
this  branch.  To  the  visits  of  the  general  practitioner  there  should  be  no 
rule  of  limitation,  for  after  the  convalescence  of  the  mother  he  is  needed 
for  the  supervision  of  the  baby  and  perhaps  for  other  medical  needs  in 
the  family. 

For  the  specialist,  however,  there  should  be  a  hard-and-fast  rule,  and  the 
one  which  has  seemed  to  the  author  the  most  satisfactory  is  to  limit  the 
visits  to  one  month  and  then  refer  the  patient  back  to  the  physician  by 
whom  she  was  referred,  or,  if  not  referred  to  him  by  a  physician,  to  recom- 
mend her  either  to  a  pediatrist  or  to  a  general  practitioner.  It  is  always 
a  mistake  for  the  obstetrician  to  remain  in  charge  of  a  referred  case  for 
a  moment  after  his  services  as  obstetrician  are  needed.  It  is  also  a  mis- 
take for  the  obstetrician  to  prescribe  for  any  ailment  of  any  other  member 
of  the  family  while  attending  a  referred  obstetric  case.  He  will  retain 
the  respect  and  good  will  of  the  family  physician  who  referred  the  case 
only  by  performing  his  services  as  obstetrician  and  referring  the  patient 
back  to  him  at  the  end  of  the  obstetric  month. 

Furthermore,  even  if  the  case  comes  to  the  obstetrician  independently, 
without  being  referred,  the  most  satisfactory  rule  of  practice  is  to  refer 
the  patient  to  some  one  else  at  the  end  of  the  obstetric  month  as  after 
that  there  is  no  good  "line  of  demarcation"  where  the  obstetrician  can 
say  his  services  are  no  longer  needed,  for  the  baby  may  contract  some 


378  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

contagious  disease,  and  to  leave  the  baby  when  it  is  ill  without  oU'ending 
the  mother  is  a  nn)st  difficult  precedure.  As  suggested  above  the  only 
satisfactory  rule  is  the  obstetric  month  for  the  ohstetricuiu. 

The  Obstetrical  Fee. — A  word  here  regarding  the  obstetrical  fee  may 
not  be  amiss.  Of  course  every  obstetrician  has  a  method  of  his  own, 
a  method  of  doing  his  work,  a  method  of  charging,  a  method  of  book 
keei)ing. 

Furthermore  he  usually  has  or  should  have  a  reason  for  his  method. 

The  method  of  charging,  which  after  many  years  of  active  obstetrical 
work  has  seemed  to  the  author  the  most  satisfactory,  has  been  to  charge 
an  inclusive  fee,  stated  to  the  family  beforehand,  which  will  include  the 
care  during  confinement  and  also  the  visits  during  the  obstetric  month. 
Office  or  house  visits  and  examinations  of  the  urine  during  pregnancy 
are  not  included  in  this  fee,  and  if  on  account  of  an  operative  delivery  the 
services  of  one  or  more  assistants  are  needed  an  additional  charge  is  made. 

The  author's  reason  for  including  in  his  obstetrical  fee  the  puerperal 
visits  is  as  follows:  The  obstetrician's  chief  aim  is,  or  should  be,  the 
welfare  of  the  mother  and  her  child.  If  everything  is  not  progressing 
absolutely  smoothly  it  is  a  great  comfort,  alike  to  the  patients  and  obstet- 
rician, for  him  to  feel  that  he  can  make  as  many  visits  each  day  as  he 
wishes  to  assure  himself  that  conditions  are  satisfactory,  or  to  attempt 
to  make  them  so. 

Visits  of  Friends. — During  the  first  week  of  the  puerperium  the  quieter 
a  patient  can  be  kej)t  the  better.  This  means  that  visitors  outside  the 
immediate  members  of  the  family  should  be  excluded — a  field  for  the 
exercise  of  great  tact  on  the  part  of  the  obstetrician. 

It  is  usually  necessary  to  allow  the  mother  and  perhaps  the  mother- 
in-law,  scmietimes  the  father  and  occasionally  the  father-in-law  to  see 
the  patient  in  the  first  twenty-four  hours,  but  other  members  of  the 
family  can  usually  be  pacified  by  being  shown  the  baby.  In  this  connec- 
tion attention  may  well  be  called  to  the  fact  that  visitors  with  colds  or 
other  infections  about  them  are  a  source  of  danger  in  the  nursery  and 
should  be  excluded. 

It  should  be  remembered  that  on  the  day  following  a  confinement  a 
patient  often  seems  stronger  than  she  really  is.  The  contrast  to  the  .suffer- 
ing of  the  day  or  night  before,  the  realization  that  the  dreaded  event 
is  over,  the  joy  of  the  presence  of  the  newborn  babe — her  own,  all  con- 
spire to  a  condition  of  exultation  which  produces  a  false  appearance  of 
both  physical  and  nerve  strength  in  the  mother  which  may  be  mis- 
leading. 

She  probably  feels  stronger  than  she  will  on  the  third  day  when  the 
breasts  distend  and  begin  their  function  of  lactation.  The  strength  of 
the  patient  should  be  conserved  to  meet  the  future  demands  and,  further- 
more, excitement  from  visitors  may  through  vasomotor  action  favor 
uterine  relaxation. 

Outline  of  Convalesence. — One  of  the  first  questions  asked  by  the 
patient  or  her  friends  is  in  regard  to  the  duration  of  her  stay  in  bed  or 
in  the  house.    The  author's  outline  of  privileges  is  as  follows: 


LACTATION  379 

Any  time  after  the  fourth  day,  if  there  has  been  no  perineal  operation, 
the  patient  may  sit  on  the  commode  long  enough  to  void  urine  or  evacu- 
ate the  bowel.  It  is  better  not  to  try  to  have  a  movement  of  the  bowels 
on  the  first  day  of  her  sitting  up  on  the  commode  lest  she  feel  faint. 

On  the  ninth  day  she  may  sit  up  in  bed  for  an  hour  and  on  the  tenth 
day  she  may  sit  up  for  an  hour  in  a  chair. 

After  the  tenth  day  she  may  add  an  hour  each  day  to  the  time  she  sits 
up  until  she  has  the  privilege  of  sitting  as  long  as  she  desires,  better 
dividing  the  time  between  morning,  afternoon,  and  evening. 

At  the  end  of  three  weeks  she  walks  about  the  floor  and  at  the  end  of 
four  weeks  she  is  allowed  downstairs  and  out  for  a  drive. 

LACTATION. 

One  of  the  most  important  problems  which  the  obstetrician  has  to 
face,  next  to  the  mechanical  problem  of  delivery,  is  the  nourishment  of 
the  baby  he  has  brought  into  the  world.  If  the  mother  has  a  well- 
developed  breast  with  a  good  milk  supply  the  solution  of  the  problem 
is  usually  easy,  but  unfortunately  this  is  often  not  the  case.  One  of 
the  penalties  of  modern  civilization  seems  in  many  instances  to  be  an 
inability  on  the  part  of  the  mother  to  supply  proper  food  either  in  quantity 
or  quality  for  her  child.    The  exact  reason  for  this  is  often  obscure. 

In  some  cases  the  grandmother  and  the  great-grandmother  of  the 
child  were  unwilling  to  nurse  because  unwilling  to  spare  sufficient  time 
from  their  social  duties.  In  other  cases  the  overtaxing  of  the  nervous 
system  by  study  or  social  duties  at  a  time  when  the  pelvic  organs  and 
breasts  should  have  been  developing  has  left  imperfect  development  in 
each.  Fortunately  at  the  present  time  the  laity  are  so  well  educated  to 
the  fact  of  the  importance  of  a  good  breast  of  milk  for  the  well-being  of 
the  child,  and  the  annoyance  and  anxiety  sometimes  associated  with 
artificial  feeding,  that  most  mothers  are  willing,  if  not  anxious,  to  nurse 
their  child  at  least  for  a  few  months.  The  ability  to  nurse  a  child  success- 
fully is  one  of  the  greatest  blessings  alike  to  mother,  to  child,  and  to 
obstetrician.  It  brings  mother  and  child  together  in  every  sense  of  the 
word  as  nothing  else  can  or  will,  and  develops  a  maternal  love  which 
those  deprived  of  it  do  not  realize.  To  the  child  it  usually  means  peaceful 
days  and  nights  and  a  steady  gain.  To  the  obstetrician  it  generally 
means  absence  of  anxiety  as  far  as  the  child  is  concerned.  As  long  as 
nothing  equals  a  good  breast  of  mother's  milk  for  the  nourishment  of  the 
child  it  is  important  that  the  obstetrician  should  understand  both  the 
anatomy  and  the  physiology  of  the  breast. 

The  Breast. — The  anatomy  of  the  breast  has  already  been  described 
(see  page  50).  It  will  be  sufficient  in  review  simply  to  mention  the  fact 
that  its  secreting  structure  consists  of  from  15  to  20  lobes  which  in  turn 
are  composed  of  a  number  of  lobules.  The  canals  of  the  lobules  unite 
to  form  the  excretory  ducts  of  the  lobes,  called  the  lactiferous  duds, 
which,  15  to  20  in  number,  converge  toward  the  nipple  on  the  surface 
of  which  thev  terminate. 


380 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


Colostrum. — During  the  latter  part  of  pregnancy  and  the  first  two  or 
three  days  of  the  i)uerperium  there  can  be  expressed  from  the  nipple  a 
thin,  yellowish  fluid  called  colostrum.  The  yellow  color  is  usually  assigned 
to  the  colostrum  corpuscles.  According  to  Kiduie  it  is  due  to  a  pigment 
resembling  the  coloring  matter  in  the  cells  of  the  corpus  luteiun.  This 
yellow  color  may  be  very  slight  but  usually  just  before  the  secretion  of 
the  true  milk  it  is  very  pronounced.  The  colostrum  is  composed  largely 
of  serum  albumen  and  coagulates  on  boiling.  It  contains  more  protein 
and  more  salts  than  the  average  woman's  milk,  but  less  sugar  and  less 
fat  as  will  be  seen  from  the  following  tables  quoted  from  Holt:^ 


Fig.  273. — Human  milk,  first  day,  showing  colostrum  corpuscles. 

Colostrum.  Average  woman's  milk. 

Fat 2.04  3.50 

Sugar 3.74  7.00 

Protein .        5.71  1.25 

Salts 0.28  0.20 

Water 88.23  88.05 

Colostrum  has  a  specific  gravity  of  1.030  to  1.040  and  is  alkaline  in 
reaction.  Under  the  microscope  (see  Fig.  273)  it  is  seen  to  consist  of 
large,  granular  bodies  called  colostrum  corpuscles,  and  fat  droplets  of 
various  sizes. 

The  colostrum  corpuscles  are  cast  off  epithelial  cells  which  have  under- 
gone fatty  degeneration. 


*  Diseases  of  Infancy  and  Childhood. 


LACTATION 


381 


The  appearance  in  the  microscopic  field  difl'ers  greatly  from  that  of 
the  perfect  emulsion  seen  in  normal  human  milk  (see  Fig.  275).  On  the 
third  or  fourth  day  in  primiparse,  often  at  the  close  of  the  second  day  in 
multiparse,  the  breasts  become  engorged;  they  feel  hot,  full  and  tender 
to  the  patient  and  on  palpation  they  feel  larger  and  firmer,  and  the 
distended  milk  ducts  can  be  easily  palpated.  The  fluid  which  can  be 
expressed  from  the  nipple  has  now  increased  and  contains  more  of  the 
fat  droplets  of  ordinary  milk  intermingled  with  the  colostrum  corpuscles 
(see  Fig.  274).  Colostrum  has  little  nutritive  value  but  is  supposed  to 
act  as  a  laxative  and  clear  the  baby's  intestinal  canal  of  meconium  and 
so  prepare  the  way  for  milk  digestion. 


Fig.  274. — Human  milk,  third  day. 


As  the  days  go  by  the  colostrum  corpuscles  are  seen  to  diminish  and 
the  even,  perfect  emulsion  of  normal  human  milk  (see  Fig.  275)  takes 
the  place  of  the  irregular  emulsion  seen  in  colostrum.  The  colostrum 
corpuscles  should  have  disappeared  by  the  tenth  or  twelfth  day. 

Woman's  Milk. — Normal  woman's  milk  is  bluish-white  in  color  and 
is  usually,  even  when  freshly  drawn,  amphoteric  to  litmus  or  slightly 
acid  to  phenolphthalein.  It  varies  in  specific  gravity  from  1.026  to  1.036, 
with  an  average  of  1.031  at  a  temperature  of  60°  F.  Under  the  micro- 
scope woman's  milk  is  seen  to  be  composed  of  numerous  round,  fat  drop- 
lets of  nearly  uniform  size  (see  Fig.  275)  called  milk  corpuscles,  suspended 
in  a  clear  fluid.  Acetic  acid  when  added  to  woman's  milk  causes  small 
flocculi,  never  the  large,  firm  coagula  as  seen  when  it  is  added  to  cow's 


382  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

milk.  The  composition  of  average  woman's  milk  is  seen  in  tlie  table  given 
al)o\e  where  it  is  compared  with  woman's  colostrum. 

Mother's  Condition. — As  the  breasts  become  engorged  and  the  secretion 
of  milk  begins,  the  woman,  especially  if  she  is  of  a  nervous  disposition, 
often  shows  quite  a  little  general  reaction.  The  breasts  are  hot  and 
l)ainful,  she  may  have  a  headache  and,  especially  if  she  is  a  primipara, 
the  nursing  of  the  baby  on  the  sensiti^'e  nipples  may  give  rise  to  so  much 
general  discomfort  that  not  infrequently  a  slight  rise  of  temperature 
accompanies  the  inception  of  lactation. 

A  temperature  of  100°  to  100.0°  F.,  which  appears  on  the  third  or  fourth 
day  of  the  puerperium,  w^iile  the  breasts  are  engorged  as  described  above, 


Fiu.  275. — Human  milk,  tenth  day. 


and  subsides  on  the  following  day  as  the  breasts  soften  and  the  milk 
supply  is  taken  care  of  by  the  baby,  may  well  be  assigned  to  the  condition 
of  the  breasts — a  breast  temperature. 

It  must  be  remembered,  however,  that  this  is  also  the  time  when  infec- 
tion is  apt  to  show  itself  by  a  rise  of  temperature,  and  the  obstetrician 
must  be  careful  not  to  overlook  a  beginning  infection  just  because  the 
breasts  are  a  little  distended.  Years  ago  many  cases  of  infection  were 
assigned  to  the  condition  of  the  breasts  and  were  called  "milk  fever." 
As  the  knowledge  of  puerperal  infection  increased  and  it  became  known 
that  puerperal  infection  was  wound  infection,  there  arose  a  tendency 
to  deny  the  existence  of  milk  fever  and  to  assign  all  rises  of  temperature 
in  the  puerperium  to  infection.    I'ndoubtedly,  as  will  be  considered  again 


LACTATION 


383 


under  Puerperal  Infection  (see  page  823),  the  pendulum  ^\\•ung  too  far  and 
the  fact  lias  now  been  established  that  painful  distended  breasts,  especially 
in  a  nervous  woman,  may  give  rise  to  a  slight  rise  of  temperature  ^\-ithoiit 
infection. 

The  Act  of  Nursing. — ]\Iost  babies  when  put  to  the  mother's  breasts 
will  take  hold  and  will  suck  as  though  always  accustomed  to  it.  Occa- 
sionally, however,  the  situation  is  markedly  different,  and  either  on 
account  of  the  condition  of  the  nipple,  or  the  character  of  the  milk,  or 
the  strength,  or  vd][  of  the  baby,  it  will  not  nurse. 

Depressed  Nipple. — On  account  of  the  previous  pressure  of  tight  cloth- 
ing, or  the  natural  conformation  of  the  nipple,  or  because  the  breast 
is  so  distended  and  firm,  the  nipple  does  not  project  beyond  the  level  of 
the  breast  and  there  is  nothing  for  the  baby  to  get  hold  of.  In  such  cases 
it  is  necessary  either  to  let  the  baby  nurse  for  a  time  through  a  nipple 
shield  (see  Fig.  276j  which  will  draw  out  the  nipple  so  the  baby  can  grasp 
it,  or  to  draw  it  out  mechanically  with  the  breast  pump,  or  breast  pump 
and  fingers,  so  as  to  accomplish  the  same  result.  Sometimes  the  use  of 
the  nipple  shield  for  a  moment  or  two  will  draw  it  out  sufficiently  so  that 
the  shield  may  then  be  discarded 
and  the  baby  be  directly  applied 
to  the  breast. 

Character  of  the  Milk. — In  some 
instances  there  is  something  in  the 
quality  of  the  mother's  milk  which 
gives  the  baby  discomfort  every 
time  it  comes  to  the  mother's 
breast.  Under  these  conditions  the 
baby  soon  refuses  to  nurse  and  the 
indication  is  a  careful  examination 

of  the  mother's  milk  and  if  possible  an  improvement  in  its  condition 
before  trying  again  to  have  the  baby  take  it. 

The  Strength  of  the  Baby. — ^Babies  which  are  premature,  or  are  other- 
wise enfeebled,  may  become  so  exhausted  in  their  endeavors  to  obtain 
nourishment  from  a  mother's  nipple  through  which  the  milk  does  not 
come  easily  that  they  are  unable  to  obtain  sufficient  nourishment. 
When  this  is  the  case  the  baby  should  not  be  put  to  the  breast  for  a 
time,  but  the  mother's  milk  should  be  drawn  off  artificially  and  given  to 
the  baby  in  a  bottle,  or  in  some  cases  by  a  medicine  dropper,  or  even  by 
gavage. 

The  Will  of  the  Baby. — It  is  astonishing  how  early  the  baby  will  develop 
a  will  of  its  own.  If  it  has  been  fed  with  sugar  solution,  or  a  preparation 
of  milk  from  a  bottle  with  a  nipple  through  which  the  fluid  flows  easily, 
the  baby  may  so  much  prefer  that  method  to  sucking  hard  on  a  breast 
from  which  the  food  does  not  come  readily  that  it  will  refuse  to  take 
the  breast.  This  situation  calls  for  much  patience  and  tact  on  the  part 
of  the  nurse.  She  must  be  careful  not  to  overtax  the  mother  by  too  pro- 
longed endeavors  to  make  the  baby  take  hold  and  nurse,  for  a  crying 
baby,  especially  her  own  crying  baby,  refusing  to  take  the  nipple  is  cer- 


FiG.  276. — The  Sloane  Hospital  nipple  shield. 


384  THE  PUERPERIUM  AND  ITS.  MANAGEMENT 

tainly  a  nerve-wearing  object;  on  the  other  hand,  it  is  only  by  patience, 
gentleness  and  perseverance  that  the  baby  is  persuaded  that  the  mother's 
breast  is  the  proper  source  of  nourishment  and  that  by  a  little  effort  of 
its  own  it  can  satisfy  its  hvmger.  In  some  cases,  if  the  baby  is  strong  and 
well,  it  may  be  necessary  to  let  the  baby  skip  a  feeding  and  in  common 
parlance  "starve  the  baby  to  it."  This,  however,  should  be  done  under 
the  supervision  of  the  obstetrician. 

It  is  often  possible  to  coax  the  baby  to  the  nipple  by  expressing  a  little 
of  the  milk  from  the  breast  first  so  as  to  soften  the  breast  and  start  the 
milk  flowing  more  freely,  also  by  taking  off  the  yellow,  colostrum  fluid 
first,  the  subsequent,  more  normal  milk  may  be  more  attractive  to  the 
baby. 

Furthermore,  by  leaving  the  nipple  bathed  with  milk  or  sugar  solution, 
the  baby  may  be  induced  to  take  it.  These  are  some  of  many  methods 
in  the  "coaxing"  process.  As  a  rule,  if  the  baby  for  one  or  two  nursings 
will  take  the  breast  normally,  the  battle  is  won  and  no  further  trouble 
need  be  expected. 

Frequency  of  Nursing. — During  the  interval  between  the  birth  of  the 
child  and  the  establishment  of  the  milk  secretion,  i.  e.,  for  two  or  some- 
times three  days  after  birth,  the  baby  should  be  put  to  the  breast  only 
every  four  hours  and  only  during  the  daytime  and  allowed  to  remain 
there  only  five  minutes.  The  reasons  for  this  have  already  been  stated 
(see  page  376).  During  this  period  the  amount  of  fluid  needed  by 
the  baby  is  supplied  in  the  shape  of  a  5  per  cent,  sugar  solution  or  plain 
boiled  water  given  at  regular  intervals,  usually  between  the  nursings. 
With  the  establishment  of  the  milk  secretion  regular  habits  of  nursing 
should  be  instituted.  During  the  first  week  of  the  baby's  life  it  usually 
needs  seven  feedings  in  the  twenty-four  hours.  This  means  that  during 
this  time  the  baby  should  be  put  to  the  breast  every  three  hours  during 
the  daytime.  It  is  desirable  to  disturb  the  mother  as  little  as  possible 
during  her  sleeping  hours,  although  during  the  first  week  it  may  be  neces- 
sary in  the  interest  of  the  hahy  and  the  comfort  of  the  mother's  breasts 
to  have  the  baby  nurse  twice  between  the  hours  of  10  p.m.  and  7  a.m. 
This  should  be  reduced  to  once  as  soon  as  possible. 

Duration  of  Nursing.— Babies  and  breasts  vary  greatly  in  the  time 
required  to  saipply  the  infant  with  a  proper  amount  of  milk  at  a  single 
nursing,  and  this  is  sometimes  best  determined  by  the  scales.  As  a  rule, 
however,  a  normal  baby  at  a  normal  breast  during  the  first  month  will 
obtain  a  sufficient  amount  of  nourishment  in  from  eight  to  twelve  minutes. 
If  the  milk  flows  very  freely  this  may  have  to  be  reduced  to  six  minutes 
and  the  baby  may  not  care  to  nurse  longer.  If,  on  the  other  hand,  the 
milk  flows  very  slowly  and  the  baby  is  large  and  strong,  twenty  minutes 
may  be  allowable.  This  should  be  considered  the  limit  of  time  for  a  single 
nursing  and  is  usually  not  reached  until  the  baby  is  several  months  old. 

Care  of  the  Breasts  and  Nipples. — ^This  may  usually  be  summed  up  in 
two  words,  support  and  cleanliness. 

As  the  breasts  become  engorged  and  heavy,  they  tend  to  sag  and  the 
ducts,  not  being  so  easily  emptied,  tend  to  become  distended,  especially 


LACTATION  385 

in  the  outer  and  lower  quadrants,  and  distended  ducts  tend  to  become 
inflamed.  Hence  it  is  that  as  a  prophylactic  measure  the  breasts  should 
be  supported  and  the  breast  binder  as  indicated  in  Fig.  242  be  applied 
not  later  than  the  second  day.  The  breast  binder  should  be  worn  until 
the  patient  is  up  and  about,  when  she  can  wear  a  loose-fitting  corset. 
It  should  be  applied  snugly  anough  to  give  support  but  not  tightly  enough 
to  markedly  compress  the  breast  and  so  diminish  the  milk  supply. 

The  nipples  should  be  cleansed  with  boric  acid  solution  before  and 
after  the  nursing.  The  secret  of  success  in  the  care  of  the  nipples  is 
cleanliness.  The  liability  to  trouble  with  the  nipples  is  lessened  if  they 
have  been  bathed  regularly  during  pregnancy  with  the  borax  and  alcohol 
solution  recommended  on  page  153. 

During  the  interval  between  nursings  the  nipples  should  be  protected 
by  a  little  square  of  sterile  lint  on  which  is  spread  some  sterilized  petrola- 
tum. This  prevents  the  binder  from  sticking  to  the  nipple  and  removing 
some  of  the  epithelium  when  it  is  loosened.  If  the  nipple  becomes 
abraded,  an  astringent  application  like  the  glyceritum  acidi  tannici  is 
very  beneficial. 

If  an  actual  crack  of  the  nipple  occurs  the  wisest  treatment  is  the 
touching  of  the  crack  with  8  per  cent,  solution  of  nitrate  of  silver,  applied 
with  a  thin  layer  of  cotton  on  a  toothpick,  and  then  letting  the  baby 
nurse  through  a  shield  for  a  few  times.  If  the  crack  in  the  nipple  is 
deep  and  difficult  to  heal  it  is  often  wise  to  discontinue  the  nursing 
for  twelve  to  twenty-four  hours,  expressing  the  milk  in  the  meantime. 

"Caked"  Breast. — If  the  ducts  of  the  breast  become  distended  and 
inflamed,  perhaps  from  sagging,  or  insufiicient  emptying,  or  from  chilling 
of  the  surface,  or  perhaps  from  the  combination  of  all  three  causes,  we 
have  a  condition  sometimes  called  "caked"  breast  or  threatened  mastitis. 
This  condition  may  be  accompanied  by  a  rigor  and  a  rapid  rise  of  tem- 
perature and  pulse,  the  temperature  going  perhaps  to  103°  to  105°  F. 

The  treatment  is  usually  best  summarized  as  follows:  Empty  the 
breasts.    Empty  the  bowels.    Apply  ice. 

The  breasts  should  be  emptied  as  much  as  possible  by  the  baby,  per- 
haps letting  it  nurse  twice  in  succession  on  that  breast  rather  than  in 
alternation  with  the  other.  The  breast  should  be  further  emptied  by 
gentle  massage  by  the  nurse  perhaps  as  often  as  every  two  hours,  care 
being  taken  not  to  bruise  the  breast  tissue  during  the  manipulation. 

In  some  cases  the  breast  is  so  tender  that  the  breast-pump  accomplishes 
the  purpose  with  less  discomfort  to  the  patient. 

Emptying  the  bowels  with  a  saline  cathartic  like  Epsom  salts  or 
Rochelle  salts  is  a  valuable  adjuvant  in  depletion  of  the  breast. 

The  use  of  the  ice-bag  on  a  nursing  breast  was  formerly  thought  to  be 
a  most  dangerous  procedure,  but  is  now  regarded  one  of  the  most  valuable 
methods  of  treating  a  painful,  engorged  breast,  and  may  be  used  freely 
not  only  in  conditions  of  inflammation,  but  in  any  condition  of  painful 
distention.  If  a  condition  of  actual  mastitis  exists,  all  massage  and 
nursing  at  the  breast  should  be  discontinued.  The  pain  is  often  relieved 
by  enveloping  the  breast  with  a  cold,  wet  dressing  of  alum  acetate 
25 


386 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


solution  or  with  ichthyol  ointment.  As  soon  as  evidences  of  pus  are 
detected  radial  incisions  and  free  drainage  are  distinct  indications.  In 
making  the  incisions  in  a  woman's  breast,  not  only  should  the  future 
usefulness  but  the  cosmetic  effect  should  be  considered.  The  incisions 
should  be  radial  so  that  as  few  milk  ducts  as  possible  are  severed.  The 
areola  should  if  possible  be  avoided  so  that  the  pigmented  area  of  the 
breast  may  not  be  disturbed  in  the  cicatrix.  The  upper  quadrants  of 
the  breast,  especially  the  upper  inner  quadrant,  should  if  possible  be 
avoided. 

Axillary  Breast  Tissue. — Occasionally  supernumerary  masses  of  milk 
ducts  occur  in  the  axilla  anrl  as  the  breasts  become  engorged  these  axillary 
masses  become  swollen  and  painful  (see  Fig.  277).  As  a  rule  they  give 
annoyance  onlj^  for  three  or  four  days  and  the  application  of  the  ice- 
bag  is  the  only  treatment  needed. 


Fig.  277. — Axillary  Ijreast  tissue. 


Quantity  and  Quality  of  Milk. — At  the  present  day  it  so  frequently 
happens  that  a  woman's  milk  is  unsatisfactory  in  either  quantity  or 
quality  that  it  is  important  for  the  obstetrician  to  ascertain  both  of 
these  conditions. 

Quantity. — In  general  there  are  two  varieties  of  methods  for  ascer- 
taining the  quantity  of  woman's  milk: 

1.  Non-instrumental  methods. 

2.  Instrumental  methods. 

Non-instrumental  Methods. — These  may  be  classified  as  follows: 

(a)  By  noting  the  time  baby  nurses. 

(6)  By  noting  the  time  baby  sleeps. 

(c)  By  inspection,  pali)ation,  and  expression. 


LACTATION  387 

Time  Bahy  Niirses. — The  mother  may  say  ''Oh,  yes;  I  have  an  abun- 
dance of  milk;  my  baby  nurses  for  half  an  hour."  This  is  pretty  positive 
exndence  that  the  quantity  is  insufficient,  otherwise  the  baby  would  be 
satisfied  in  a  much  shorter  time  and  could  not  be  induced  to  nurse  longer. 

Time  Baby  Sleeps. — If  the  baby  goes  to  sleep  immediately  after  nurs- 
ing, but  in  a  half  to  one  hom-  wakens  and  seems  hungry,  it  frequently 
means  that  the  quantity  obtained  at  the  last  nursing  was  insufficient. 

Inspection,  Palpation,  and  Expression. — One  is  often  surprised  in  the 
character  of  a  woman's  breasts.  Some  buxom-looking  women  with  large 
breasts  have  very  little  gland  tissue  and  secrete  very  little  milk.  On  the 
other  hand,  some  thin  women  with  relatively  flat  breasts,  wih  secrete 
an  abundance  of  milk.  The  fact  is  that  the  large  breast  may  be  com- 
posed chiefly  of  fat  and  be  of  very  little  value  as  a  source  of  nourishment 
for  the  baby,  while  the  thin,  small  breast  may  be  composed  chiefly  of 
gland  tissue  and  may  secrete  freely. 

These  facts  can  best  be  ascertained  by  inspection  and  palpation  of 
the  breasts  and  then  noting  the  readiness  with  which  milk  can  be  expressed 
from  the  nipple.  In  the  satisfactory  breast  the  cord-like  ducts  can  be 
felt  and  the  milk  easily  expressed;  in  the  unsatisfactory  breast  it  may 
be  found  that  the  nipple  on  which  the  baby  has  been  nursing  for  several 
days  yields  scarcely  a  drop  of  milk.  Breasts  vary  greatly  as  to  the 
amount  of  milk  present  between  nursings.  Some  breasts  have  consider- 
able milk  in  them  all  the  time,  while  in  others  the  milk  seems  to  be 
secreted  just  at  the  time  of  the  nursing,  and  the  nursing  from  one  breast 
may  even  cause  milk  to  flow  from  the  nipple  of  the  other  breast  as  well. 

Instet^iextal  Methods. — There  are  two  instruments  for  determining 
the  quantity  of  a  mother's  milk  which  are  almost  indispensable  in  the 
nursery. 

1,  The  scales. 

2.  The  thermometer. 

The  Scales. — Formerly  the  chief  use  of  the  scales  in  the  nursery  was 
to  ascertain  the  weight  of  the  baby  at  birth  and  if  the  weight  was  exag- 
gerated a  little  it  was  no  disparagement  to  the  scales.  Any  subsequent 
weighing  of  the  baby  was  largely  a  matter  of  curiosity  to  determine  if 
the  baby  had  gained  more  in  a  month  than  the  neighbor's  baby. 

The  use  of  the  scales  in  the  present-day  nursery  is  considered  just 
as  much  a  routine  daily  procedure  as  giving  the  baby  its  bath.  It  not 
only  tefls  by  the  steady  increase  in  the  weight  of  the  baby  that  the 
mother's  milk  is  sufficient  in  quantity,  but  is  also  a  strong  argument  in 
favor  of  the  quality  of  the  milk  being  as  it  should  be.  Furthermore,  by 
accurately  weighing  the  baby  before  and  after  nursing,  just  the  amount 
of  nourishment  obtained  from  the  breast  can  be  told. 

The  type  of  scales  to  be  purchased  for  the  nursery  is  a  matter  of  con- 
siderable importance.    It  should  embody  three  principles: 

1.  It  should  have  a  firm  standard. 

2.  It  should  have  a  capacious  scoop  or  basket. 

3.  It  should  register  half-ounces,  preferably  with  an  arm  along  which 
the  weight  is  passed  (see  Fig.  278). 


388 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


The  question  of  a  firm  standard  is  one  of  great  importance,  as  was  once 
demonstrated  in  the  writer's  experience.  He  had  advised  the  style  of 
scales  recommended  above,  but  as  the  family  had  in  the  house  a  scales 


Fig.  278. — Scales  for  weighing  infants. 


of  the  butcher  type,  with  dangling  scale  pan,  they  thought  this  would 
answer  and  employed  this,  suspended  from  the  gas  fixture  to  weigh  the 
baby.    Everything  went  well  for  a  few  days  but  one  morning  during  one 


WEEK  OF  AGE                                                                          | 

LBS 

21 
20 
19 
18 

13     5     7    9    11   13    15  17   19  21   2S  25  27  29   31    33  35  37   39  41   43  45  47   49    51 1 

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16 
15 
14 
13 
12 
11 
10 

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tf 

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8 

6 
5 

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Fig.  279. — Infant's  weight  chart. 


of  the  baby's  customary  jumps  and  kicks  in  the  scale  pan  it  fell  out, 
striking  its  head  on  the  floor.  Fortunately  the  baby  recovered,  but  with 
a  misshapen  head,  the  result  of  its  fall. 


LACTATION  389 

The  average  weight  of  a  baby  at  term,  as  seen  from  the  records  of  5000 
consecutive  full-term  labors  at  the  Sloane  Hospital,  is  seven  pounds 
three  ounces.  During  the  first  three  days  of  the  puerperium  the  baby 
loses  on  the  average  about  ten  ounces.  The  reason  for  this  initial  loss 
in  the  baby's  weight  lies  in  the  discharge  of  meconium  and  urine  and  the 
excess  of  tissue  waste  over  noi^ishment  taken  during  the  first  few  days 
prior  to  the  establishment  of  normal  lactation. 

"With  the  inflow  of  mother's  milk  the  baby  begins  to  gain  and  under 
proper  conditions  gains  from  half  an  ounce  to  one  ounce  per  day.  It  is 
expected  that  a  baby  on  its  mother's  milk  will  have  regained  its  birth 
weight  in  ten  days.  A  bottle-fed  baby  not  infrequently  may  require 
a  month  to  get  back  its  birth  weight. 

The  normal  weight  curve  of  a  healthy  baby  may  be  seen  in  Fig.  279. 

The  actual  amount  of  milk  daily  secreted  by  a  woman  varies  greatly 
in  different  individuals,  but  the  following  estimates,  determined  by 
weighing  the  baby  before  and  after  each  nursing,  may  be  considered  a 
fairly  accurate  average. 

During  the  first  two  weeks,  beginning  with  the  establishment  of  lacta- 
tion, 5x-xx. 

During  the  second  two  weeks  of  the  puerperium,  §xx-xxx. 

The  Thermometer.  "While  this  instrument  has  for  many  years  been 
considered  necessary  in  the  care  of  ill  babies,  the  author  can  well  remem- 
ber when  its  use  in  the  case  of  a  healthy  baby  was  unheard  of.  Like 
the  scales  it  has  come  to  be  regarded  an  important  instrument  in  the 
proper  care  of  a  baby  and  its  routine  daily  employment  a  necessity.  It 
is  one  of  the  best  instruments  for  determining  that  the  baby  in  the  first 
few  days  of  its  existence  is  obtaining  sufficient  nourishment.  Although 
there  are  many  exceptional  causes  of  rise  of  temperature,  the  most 
usual  cause  of  a  baby's  high  temperature  in  the  first  two  or  three  days 
is  insufficient  nourishment,  especially  fluid,  and  this  temperature  is  often 
spoken  of  as  "inanition  fever"  or  "starvation  temperature." 

The  frequency  of  occurrence  of  this  rise  of  temperature  may  be  learned 
from  the  fact  that  in  a  consecutive  series  of  500  babies  born  at  the  Sloane 
Hospital,  135  showed  this  fever.  The  highest  temperature  was  usually 
reached  on  the  third  or  fourth  day  and  the  average  duration  was  three 
days. 

In  about  two-thirds  of  the  cases  the  temperature  did  not  rise  above 
102°  F.,  although  in  9  it  reached  104°  F.,  and  in  one  106°  F.  The  descent 
to  normal  as  soon,  as  the  baby  received  sufficient  nourishment  was  usually 
sudden,  although  occasionally  gradual. 

The  babies  during  the  inanition  fever  usually  lose  weight  steadily  and 
do  not  begin  to  gain  until  the  temperature  reaches  normal.  In  the  series 
of  135  cases  at  the  Sloane  Hospital  the  loss  of  weight  among  those  with 
inanition  fever  was  double  that  of  those  without  fever.  In  1  case  it 
amounted  to  twenty-eight  ounces. 

Before  this  condition  was  well  understood  the  author  met  with  a  very 
sad  experience  in  the  family  of  a  friend  which  illustrated  it.  The  first 
baby  in  this  family,  nursing  from  its  mother's  breast,  which  was  appar- 


390 


THE  PUERPERIUM  AXD  ITS  MANAGEMENT 


ciitlx  funiisliin^  sufficient  nourisliinent,  but  was  not,  suddenly  ran  a 
liiflli  temi)eraturt\  tlie  skin  became  dry,  the  fontanelle  dej)ressed.  The 
baby  faded  Uke  a  flower  and  died  apparently  of  exliaustion. 

The  second  child,  a  boy,  weighed  at  birth  Sj  pounds  and  was  apparently 
\igorous.  During  the  first  fort\-eight  hours  its  loss  in  weight  was  5| 
ounces.  During  the  next  twenty-four  hours  he  lost  S  ounces.  His 
temperature  had  then  gradually  risen  till  it  reached  102. S°  F.;  his  lips 
and  skin  were  dry;  the  fontanelles  depressed  and  the  child  apathetic. 
Smce  the  experience  wath  the  preceding  child  the  condition  of  inanition 
fever  hafl  become  recognized  and  now  on  attempting  to  express  milk 
from  the  mother's  nipples  it  was  found  impossible.  The  child  was 
immediately  given  water  freely  and  before  midnight  a  wet-nurse  with 
abundant  milk  supply  was  secured  and  by  the  following  morning  the 
baby's  temperature  was  normal  and  remained  so. 


I 

■-> 

3 

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Fig.  280. — Temperature  chart.     Inanition  fever. 


During  the  next  four  days  he  gained  18  ounces.  The  temperature 
chart  of  this  case  is  shown  in  Fig.  280.  The  thermometer  showed  the 
danger  to  which  the  baby  was  exposed. 

The  rectal  temperature  of  the  baby  should  be  taken  night  and  morning 
for  the  first  ten  to  fourteen  days  and  once  a  day  after  that  during  the 
obstetric  month.  A  rise  of  temperature  in  the  first  few  days,  other  condi- 
tions being  normal,  should  always  suggest  a  lack  of  fluid  nourishment. 
If  the  mother's  milk  secretion  is  delayed  the  baby  should  either  be 
given  sugar  solution  every  three  hours,  or  put  upon  a  weak  formula  of 
modified  milk. 

Mixed  Feedings. — Some  women,  although  unable  to  furnish  from  the 
breasts  the  entire  amount  of  nourishment  needed  by  the  baby,  can  fur- 
nish a  certain  amount,  whicli  agrees  perfectly  with  the  baby.     Under 


LACTATION  391 

these  circumstances  it  is  wise  to  make  use  of  mixed  feedings,  i.  e.,  supple- 
ment the  mother's  milk  with  a  certain  number  of  bottles  of  modified 
cow's  milk.  The  method  of  using  supplemental  food  varies  in  different 
cases.  Some  women,  if  they  are  allowed  to  have  an  uninterrupted  sleep 
at  night  by  the  substitution  of  a  bottle  for  the  breast  at  night,  are  able 
to  supply  the  rest  of  the  nourishment  without  difficulty. 

With  other  women  the  baby  needs  more  frequent  supplemental  feed- 
ing and  here  it  is  usually  the  best  plan,  after  determining  by  weighing 
the  baby  before  and  after  nursing,  just  how  much  the  baby  obtains  from 
the  breast,  to  give  after  each  nursing  a  bottle  containing  sufficient  modi- 
fied milk  to  make  up  the  required  amount.  The  method  of  nursing  at 
the  regular  intervals  and  giving  a  supplemental  feeding  if  needed  is 
usually  better  than  alternately  giving  the  breast  and  the  bottle,  as  under 
the  less  frequent  stimulation  of  the  breasts  the  milk  supply  rapidly 
diminishes. 

Quality. — ^Aside  from  the  quantity  of  the  mother's  milk,  the  fault  may 
lie  in  the  quality  of  the  milk  supplied  to  the  baby. 

In  order  to  recognize  the  abnormal  character  of  milk  the  obstetrician 
should  familiarize  himself  with  the  normal  constituents. 

Woman's  milk  contains  fats,  sugar,  protein,  salts,  and  water. 

Fats. — The  fats  are  the  chief  source  of  animal  heat.  Their  caloric 
value  being  more  than  double  that  of  the  carbohydrates  or  the  protein. 

Thus  1  gram  of  fat  yields  9.3  calories,  while  1  gram  of  either 
carbohydrate  or  protein  yields  only  4.1  calories.  The  fats  are  very  impor- 
tant in  the  normal  development  of  the  nervous  system  and  in  bone  growth. 
They  save  nitrogenous  waste  and  increase  the  body  weight.  Fat  serves 
an  important  function  in  maintaining  the  proper  consistency  of  the 
stool. 

Thus  even  an  excess  of  fat  over  that  needed  for  absorption  is  of  value 
when  properly  digested,  but  attention  must  be  called  to  the  fact  that  in 
some  instances  the  baby  has  difficulty  in  digesting  fat  and  even  the 
butter-fat  of  woman's  milk  which  is  much  easier  to  digest  than  the  butter- 
fat  of  cow's  milk  may  cause  trouble.  The  fat  in  woman's  milk  is  in  the 
form  of  an  emulsion  of  minute  globules  in  an  albuminous  solution. 

Sugar. — The  sugar  of  woman's  milk  is  in  the  form  of  lactose  and  is  in 
solution.  Its  proportion  is  very  uniform,  and  as  it  too  is  one  of  the  sources 
of  animal  heat,  its  uniformity  is  important.  The  sugar  is  partly  converted 
into  fat  and  so  increases  body  weight. 

Protein. — This  is  a  constituent  of  food  which  is  essential  to  the  life 
and  development  of  the  child  since  it  is  the  only  kind  of  food  capable  of 
replacing  the  nitrogenous  waste  of  the  body.  It  is  also  essential  for  the 
growth  of  the  cells  of  the  body,  hence  in  the  infant  a  relatively  large 
amount  is  required.  The  chief  forms  of  protein  in  woman's  milk  are 
casein  and  lactalbumin.  The  casein  is  held  in  suspension  by  the  calcium 
phosphate  with  which  it  is  combined,  while  the  lactalbumin  is  in  solution 
and  resembles  the  serum  albumin  of  the  blood. 

The  Mineral  Salts. — ^These  are  more  important  in  early  infancy  than 
later  in  life  because  essential  in  the  building  up  of  the  osseous  system  of 


392  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

the  body.  The  most  important  of  the  mineral  salts  are  the  phosphates 
of  lime  and  magnesium  which  are  found  in  abundance  in  woman's  milk. 
Water. — A  large  percentage  of  all  animal  food  is  water.  It  is  important 
in  woman's  milk  for  the  solution  of  some  of  the  constituents,  as  the  sugar, 
the  salts  and  some  of  the  protein  and  the  suspension  of  the  rest  of  the 
protem  and  the  fat  emulsion.  Woman's  milk  contains  such  a  large  per- 
centage of  it,  as  seen  in  the  table  given  below,  that  when  the  baby  is  on 
breast  milk  as  its  sole  diet,  little  additional  water  is  required.  The 
amounts  of  these  different  ingredients  in  normal  woman's  milk  may  be 
seen  from  the  following  table: 


NORMAL  WOMAN'S  MILK. 

Fat:  In  minute  globules  in  permanent  emulsion,  3.5  per  cent. 

Sugar:  As  lactose,  7  per  cent. 

Protein:  The  most  important  forms  are  casein  and  lactalbumin, 
casein  held  in  suspension  by  calcium  phosphate,  and  lactalbumin  in 
solution,  1.25  per  cent. 

Salts:  All  in  solution  except  calcium  phosphate,  0.2  per  cent. 

Water:  88.05  per  cent. 

Examination  of  Woman's  Milk. — Although  for  a  complete  analysis  of 
woman's  milk  the  services  of  a  trained  chemist  and  a  laboratory  are 
needed,  an  approximate  clinical  examination  may  be  made  by  the 
obstetrician  by  means  of  the  Holt's  milk  set  (see  Fig.  281)  which  consists 
of  a  lactometer  and  a  cream  gauge.  With  this  set,  some  litmus  paper 
and  a  microscope,  an  approximate  clinical  examination  of  a  woman's 
milk  can  be  made. 

The  specimen  taken  for  examination  should,  according  to  Holt,  be  either 
the  middle  portion  of  the  milk,  i.  e.,  after  nursing  two  or  three  minutes, 
or  better,  the  entire  quantity  from  one  breast,  since  the  composition  of 
the  milk  will  differ  greatly  according  to  the  time  when  it  is  taken.  The 
first  milk  being  slightly  richer  in  protein  and  much  poorer  in  fat,  while 
the  last  drawn  from  the  breast  is  low  in  protein  and  high  in  fat. 

The  reaction  is  tested  with  litmus  paper. 

The  specific  gravity  is  taken  with  the  lactometer  (P'ig.  281  A)  as  with 
an  urinometer.  Attention  may  be  directed  to  the  fact  that  the  specific 
gravity  is  lowered  by  the  fat  and  raised  by  the  other  solids. 

Estimation  of  Fat. — This  is  done  by  the  use  of  the  cream  gauge 
(Fig.  281  B),  the'  results  of  which,  although  only  approximate,  are 
sufficiently  accurate  for  clinical  purposes. 

The  tube  is  filled  to  the  zero  mark  with  fresh  milk  and  then  allowed  to 
stand  at  the  temperature  of  the  room  for  twenty-four  hours,  when  the 
percentage  of  cream  is  read  off.  The  ratio  of  the  cream  to  the  fat  is 
approximately  five  to  three.  Thus  5  per  cent,  of  cream  means  3  per  cent, 
of  fat. 

Sugar. — The  percentage  of  sugar  in  woman's  milk  is  so  nearly  constant 
that  it  is  disregarded  in  the  clinical  examinations. 


EXAMINATION  OF  WOMAN'S  MILK 


393 


i.oiu 


1,010 


\ 


L_J 


Protein. — ^There  is  no  accurate,  simple  method  for  determining  the 
amount  of  protein  in  milk,  but  an  approximate  idea  may  be  obtained 
from  a  knowledge  of  the  specific  gravity  and  the  percentage  of  fat  if 
the  sugar  and  salts  are  regarded  as  so  nearly  constant  as  not  likely  to 
affect  the  specific  gravity.  The  specific  gravity  will  then  vary  directly 
with  the  proportion  of  protein  and  inversely  with  the  proportion  of  fat. 
Thus  high  protein,  high  specific  gravity;  high  fat,  low  specific  gravity. 
By  this  method  can  be  told  whether  the  protein  is  excessively  high  or 
excessively  low  and  is  sufficient  for  practical  purposes. 

Effect  of  Diet  on  Woman's  Milk. — 
The  sugar  in  woman's  milk  is  but 
little  affected  by  her  diet,  but  the 
fat  and  the  protein  may  be  distinctly 
influenced  by  it.  The  fat  is  increased 
by  a  diet  rich  in  fats  and  carbohy- 
drates, especially  if  no  exercise  is 
taken.  It  is  decreased  by  shutting 
oft*  fats  and  carbohydrates,  substi- 
tuting vegetables  therefor  and  in- 
creasing the  amount  of  exercise.  In 
general,  a  low  diet  lowers  the  fat.  The 
protein  is  increased  by  overeating, 
especially  of  meats  and  vegetables, 
with  little  exercise,  and  decreased  by 
the  opposite  course.  All  fluids  tend 
to  increase  the  amount  of  milk  and 
the  alcoholic  malt  extracts  tend  to 
increase  both  the  amount  of  milk 
and  the  amount  of  fat.  Certain 
gruels,  such  as  cornmeal  gruel,  have 
a  similar  tendency. 

Effect  of  Menstruation  on  Woman's 
Milk. — Although  amenorrhea  is  the 
rule  during  lactation,  not  infre- 
quently a  nursing  mother  finds  that 
she  is  menstruating  and  this  menstru- 
ation once  reestablished  is  apt  to  con- 
tinue with  more  or  less  regularity 
during    the    lactation    period.      The 

question  naturally  arises,  shall  she  continue  nursing  while  menstruating? 
The  disturbance  produced  by  menstruation  varies  greatly  in  different 
individuals,  but  as  a  rule,  even  if  there  was  marked  dysmenorrhea  before 
pregnancy,  after  the  birth  of  a  child  the  disturbance  is  slight  and  the 
baby  is  much  less  upset  by  the  continuance  of  nursing  from  the  breast 
during  menstruation  than  it  would  be  by  a  change  to  artificial  food. 

Effect  of  Pregnancy  on  Woman's  Milk. — The  milk  of  a  pregnant  woman 
is  usually  insufficient  in  quantity  for  a  nursing  infant  and  also  is  poor 
in  quality.    For  these  reasons  and  also  from  the  fact  that  the  stimulation 


B 


Fig.  281.  —  Holt's  lactometer  and 
cream  gauge  for  examination  of 
woman's    milk. 


394  THE  PUERPERIUM  AXD  ITS   MAX  AGE  ME  NT 

of  the  nipple  by  the  suckling  of  the  child  tends  to  the  production  of  a 
miscarriage,  nursing  at  the  breast  should  be  discontinued  as  soon  as  the 
diagnosis  of  another  pregnancy  is  made. 

Effect  of  Nervous  Impressions  on  Mother's  Milk. — Dairymen  hnd  that  the 
cow  who  is  i)lacid  in  disi)osition  and  is  protected  from  sources  of  nervous 
irritation,  whether  it  be  from  dogs,  from  the  bull,  or  from  human  beings, 
gives  the  best  milk  to  the  growing  calf.  In  like  manner  the  mother 
who  is  of  a  placid  temperament  and  is  not  annoyed  or  nervously  upset 
by  sources  of  irritation  in  the  domestic  or  social  world  makes  the  best 
human  cow. 

Some  women  by  nature  are  unfitted  for  one  of  the  highest  privileges 
and  duties  of  motherhood — the  nursing  of  their  children.  Nervous, 
hysterical,  irritable  and  without  control,  how  could  it  be  expected  that 
such  a  woman  would  give  good  milk?  It  cannot  be  expected  and  they 
do  not  give  it. 

They  may  be  able  to  nurse  during  the  obstetric  month  while  they  are 
under  the  care  of  the  nurse  and  the  obstetrician  and  are  shielded  alike 
from  the  annoyance  of  the  kitchen  and  the  social  world,  but  as  soon  as 
they  begin  to  mingle  in  society  and  take  up  the  duties  of  life,  the  baby 
usually  suffers  from  indigestion,  worries,  does  not  gain  and  has  to  be 
provided  with  some  other  source  of  nourishment. 

The  Wet-nurse. — Realizing  that  nothing  equals  good  breast  milk 
for  the  nourishment  of  the  baby  it  has  been  natural  in  the  past,  when 
the  mother's  milk  has  failed,  to  turn  first  to  a  wet-nurse  if  one  could  be 
found. 

Fortunately,  the  knowledge  of  artificial  feeding  with  modified  cow's 
milk  has  greatly  increased,  and  although  at  times  a  wet-nurse  is  almost 
indispensable  to  the  life  of  the  baby,  she  is  looked  upon  at  the  present 
day  as  a  last  resort,  and  as  a  rule  only  employed  in  the  case  of  a  premature 
baby  or  one  with  whom  all  forms  of  cow's  milk  seem  to  disagree. 

The  reasons  for  this  reluctance  in  the  employment  of  wet-nurses  are 
obvious.  The  class  of  women  who  have  been  willing  to  accept  such  a 
position  has  usually  been  of  a  low  grade  and  people  of  refinement  dislike 
to  have  them  in  their  households.  ^Moreover,  the  fear  of  infection  of  the 
baby  with  some  constitutional  disease,  especially  s\'philis  or  tuberculosis, 
has  not  been  groundless.  There  are  times,  however,  when  the  life  of  the 
baby  hangs  in  the  balance  and  a  mother  is  willing  to  waive  all  feelings 
of  sentiment  in  the  interest  of  the  baby. 

Selection  of  a  Wet-nurse. — The  most  important  thing  in  the  selection 
of  a  wet-nurse  is  that  she  should  be  healthy  and  especially  that  she 
should  be  free  from  venereal  diseases  and  tuberculosis. 

Syphilis,  the  most  important  of  these,  can  usually  be  detected  by 
means  of  the  Wassermann  reaction  and  the  obstetrician,  on  whom 
the  responsibility  usually  rests  in  the  selection  of  a  wet-nurse,  should 
never  recommend  one  unless  she  has  been  found  negative  to  the  Wasser- 
mann  test.  The  infection  of  a  baby  with  gonorrhea  by  an  attendant 
suffering  with  it  is  so  easy  through  the  medium  of  the  hands,  clothing, 
etc.,  that  detection  of  it  in  the  proposed  wet-nurse  is  extremely  important. 


NORMAL  WOMAN*S  MILK  395 

Much  can  be  learned  from  the  history  of  the  woman  and  her  baby 
but  here,  unfortunately,  the  story  of  the  candidate  cannot  always  be 
relied  upon.  A  history  of  marked  vaginal  discharge  and  irritable  bladder 
or  symptoms  of  pelvic  inflammation  on  the  part  of  the  woman  and  a 
history  of  ophthalmia  in  the  case  of  the  baby  should  always  be  looked 
upon  with  suspicion,  but  before  gonorrhea  can  be  positively  excluded, 
a  physical  examination  should  be  made  of  the  woman  and  a  smear  taken 
from  any  vaginal  discharge  present. 

In  excluding  tuberculous  infection  in  the  wet-nurse,  not  only  should  the 
lungs  be  carefully  examined,  but  search  should  be  made  for  the  cicatrices 
of  tuberculous  abscesses  especially  in  the  neck  where  tuberculous  glands 
are  so  common.  Having  found  the  woman  healthy  both  on  general  and 
local  examination  the  next  question  concerns  her  breasts.  The  object 
desired  is  a  good,  healthy,  human  cow,  with  plenty  of  milk,  which  flows 
freely  through  nipples  which  are  easy  for  the  baby  to  suckle.  Here  again 
inspection,  palpation  and  expression  are  important,  for  by  them  the 
physical  features  of  the  breast  and  the  abundance  of  the  milk  can  be 
determined. 

Some  wet-nurses  with  plenty  of  milk  have  to  be  excluded  on  account 
of  the  nipples  being  so  depressed  that  a  baby  who  is  feeble,  as  is  likely  to 
be  the  condition  in  the  case  for  which  the  wet-nurse  is  required,  could  not 
extract  it. 

A  breast,  not  too  large,  with  prominent  veins,  a  rather  small  but  promi- 
nent nipple,  from  which  the  milk  can  be  expressed  in  a  stream,  presents 
the  most  satisfactory  picture. 

The  quality  of  the  milk  secreted  by  the  proposed  wet-nurse  can  be 
determined  in  two  ways. 

1.  By  inspection  of  her  baby. 

2.  By  examination. 

Much  can  be  told  from  the  condition  of  the  baby  of  the  proposed  wet- 
nurse.  If  it  is  gaining  steadily,  sleeps  well,  appears  happy,  has  normal 
stools  and  its  skin  is  free  from  eruption,  its  mother's  milk  is  in  all  proba- 
bility good.  This  probability  can  be  made  a  practical  certainty  by 
examination  with  the  milk  set  as  indicated  on  page  392. 

In  the  selection  of  a  wet-nurse  the  obstetrician  must  not  be  too  particu- 
lar about  the  marriage  of  the  candidate.  Some  of  the  best  wet-nurses  are 
those  who,  having  come  from  the  outlying  districts  of  the  old  country 
where  the  marriage  relations  are  lax  and  ignorance  widespread,  find  them- 
selves pregnant  on  landing  on  our  shores  and  on  leaving  the  maternity 
hospitals  have  no  better  means  of  support  than  that  offered  by  the 
occupation  of  wet-nurse.  Furthermore,  there  are  certain  advantages  to 
the  family  employing  the  wet-nurse,  in  having  no  husband  around  to 
annoy  by  calling,  or  to  upset  the  wet-nurse  by  reports  as  to  the  conditions 
at  her  home. 

One  of  the  problems  which  often  presents  is,  what  to  do  with  the  baby 
of  the  wet-nurse.  In  some  instances,  rare  of  course,  it  is  wise  to  let  the 
wet-nurse  bring  her  baby  with  her.  The  feeble  baby  of  the  patient  may 
be  able  to  nurse  only  a  little  and  unless  the  breasts  of  the  wet-nurse  are 


396  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

well  eni])tie(l  by  the  str()n<>;  l)al)\'  the  milk  supply  rapidly  (liiiiinishes. 
As  a  rule,  liowexer,  the  hahy  of  the  wet-nurse  has  to  he  eared  for  either 
in  one  of  the  foundlinji;  h()sj)itals  or  hy  one  of  the  nurse's  friends. 

The  diet  of  the  wet-nurse  in  her  new  surroundings  is  a  matter  of  con- 
siderable importance.  What  she  needs  is  f^ood,  plain,  milk-producing 
food,  not  the  luxuries  of  the  table  which  would  be  likely  to  u})set  her 
digestion.  Bread  and  butter,  milk,  eggs,  cereals,  cooked  fruits,  meat  and 
vegetables,  once  a  day;  cocoa,  very  little  tea  or  coflfee;  no  alcohol.  On 
this  dietary  and  with  careful  regulation  of  her"  bowels  with  some  such 
laxative  as  cascara  or  phenolphthalein,  and  a  little  regular  exercise  each 
day  in  the  open  air,  the  health  of  the  wet-nurse  will  usually  l)e  main- 
tained, and  her  health  often  means  the  health  of  the  baby  for  whom  her 
services  are  sought. 

Artificial  Feeding. — As  already  stated  the  wet-nurse  at  the  present 
day  is  seldom  necessary,  and  it  may  be  added  she  is  seldom  desired,  and 
a  good  one  is  often  very  difficult  to  find  when  desired.  From  this  it 
follows  that  when  artificial  feeding  is  required  cow's  milk  must  usually 
be  accepted  as  a  substitute.  Goat's  milk,  which  was  formerly  much  used 
for  this  purpose,  is  now  almost  never  employed.  A  satisfactory  substi- 
tute for  woman's  milk  must  contain  the  same  ingredients.  In  cow's  milk 
are  found  the  same  ingredients,  but  not  in  the  same  proportions.  Further- 
more, it  is  found  that  cow's  milk  differs  so  in  digestibility  from  woman's 
milk  that  when  the  proportions  of  the  ingredients  in  cow's  milk  are  made 
to  correspond  with  those  in  woman's  milk  the  young  baby  does  not 
digest  the  food.  However,  as  stated  above,  cow's  milk  contains  the 
ingredients  of  woman's  milk  and  can  be  modified  to  suit  the  needs  of  the 
individual  baby. 

The  first  requisite  is  to  secure  a  good  cow's  milk  and  the  first  requisite 
of  good  cow's  milk  is  that  it  be  clean  milk  from  healthy  cows. 

Healthy  Cows. — Just  as  in  the  selection  of  a  wet-nurse  it  is  considered 
of  the  utmost  importance  that  she  be  healthy,  so  in  the  selection  of  cows 
for  milk  for  infant  feeding  it  is  all  essential  that  they  be  absolutely 
healthy.  Although  the  question  of  venereal  diseases  does  not  have  to 
be  considered  in  them,  as  in  wet-nurses,  it  is  necessary  to  consider  seri- 
ously the  question  of  tuberculosis.  Tuberculous  cows  are  not  fit  to  supply 
milk  for  anyone,  least  of  all  to  babies,  as  young  mfants  are  especially 
liable  to  infection  from  bovine  tuberculosis.  From  this  it  follows  that 
all  cows  which  have  not  been  subjected  to  the  tuberculin  test  and  proved 
negative  should  be  excluded  from  the  dairy  used  for  infant  feeding. 

Clean  Milk. — INIilk  to  be  clean  must  come  from  clean  cows  in  clean 
stables,  milked  by  clean  hands  into  clean  utensils.  This  means  that 
the  best  milk  for  infant  feeding  comes  from  dairies  where  the  cows  are 
kept  with  as  much  care  as  our  best  horses,  where  the  stalls  are  kept  clean 
and  well  ventilated,  wdiere  the  cows  are  carefully  groomed,  where  the  milk- 
men during  milking  wear  clean  suits  and  have  freshly  washed  hands,  and 
see  that  the  udders  and  teats  of  the  cows  are  clean  before  taking  the  milk 
from  them.  Milking  by  electricity  eliminates  many  of  the  dangers  of 
contamination. 


MODIFICATION  OF  COW'S  MILK  397 

The  utensils  into  which  the  milk  is  received  must  have  been  recently 
cleansed  with  hot  water  or  steam  and  the  milk  thus  received  must  be 
cooled  rapidly  and  kept  cool  until  it  reaches  the  consumer,  which  should 
not  be  later  than  eighteen  hours.  These  conditions  are  fulfilled  in  the 
milk  to  which  the  Milk  Commission  of  the  County  Medical  Society  of 
New  York  allows  the  brand  of  "certified"  and  are  observed  with  special 
care  in  the  dairies  of  those  milk  laboratories  like  those  of  the  Walker- 
Gordon  Laboratory  of  New  York  and  Boston,  which  make  a  specialty 
of  modifying  cow's  milk  for  infant  feeding  according  to  prescription  by 
physicians. 

There  is  one  other  prerequisite  to  the  license  to  use  the  brand  "cer- 
tified" on  a  bottle  of  milk;  this  is  that  the  milk  does  not  contain  more 
than  ten  thousand  bacteria  to  the  cubic  centimeter.  This  condition 
can  only  be  fulfilled  by  observing  the  precautions  of  cleanliness  mentioned 
above,  but  the  milk  from  a  number  of  dairies  where  these  precautions  are 
observed  does  not  show  more  than  five  thousand  bacteria  to  the  c.c. 

Herd  Milk  Compared  to  Milk  from  a  Single  Cow. — ^The  statement  is  fre- 
quently heard  from  a  patient's  family  that  they  have  a  fine  cow,  perhaps 
a  Jersey,  and  they  can  have  her  milk  kept  just  for  the  baby's  food.  It 
is  a  duty  to  correct  the  impression  that  this  is  better  or  even  as  good  as 
milk  from  a  herd. 

No  cow  feels  equally  well  on  every  day,  and  when  not  feeling  well  her 
milk  is  not  good.  In  a  herd,  although  there  are  always  some  cows  not 
feeling  in  the  best  condition,  the  proportion  is  usually  about  the  same  and 
as  the  majority  are  feeling  well  and  the  milk  from  these  is  but  little 
influenced  by  that  from  those  not  feeling  well,  the  milk  as  a  whole  is  much 
more  uniformly  good  than  from  a  single  cow,  however  good  she  may  be 
at  the  best.  Moreover,  as  many  babies  have  a  difficulty  in  digesting 
milk  rich  in  fat,  and  milk  from  a  herd  composed  solely  of  Jersey  cows 
usually  contains  a  high  percentage  of  fat,  a  herd  composed,  aside  from 
Jerseys,  of  a  certain  number  of  cows  giving  milk  with  a  lower  percentage 
of  fat,  such  as  the  Holsteins,  has  a  distinct  advantage. 

Modification  of  Cow's  Milk. — Having  obtained  a  good,  clean  milk  from 
healthy  cows,  the  next  questions  presenting  themselves  for  consideration 
are  the  differences  between  woman's  milk  and  cow's  milk  and  the  modifi- 
cation of  the  latter  for  infant  feeding. 

Woman's  milk  and  cow's  milk,  as  already  stated,  contain  the  same 
ingredients,  but  in  different  proportions,  as  will  be  seen  from  the  following 
comparative  table: 


Woman's  milk, 

Cow's  milk 

average. 

average. 

Fat  .      .      . 

.        3.50 

4.00 

Sugar     . 

.       7.00 

4.50 

Protein 

1.25 

3.50 

Salts       .      . 

.        0.20 

0.75 

Water    . 

.      88.05 

87.25 

It  is  seen  from  the  above  that  in  cow's  milk  there  is  an  excess  of  fat, 
protein  and  salts  and  less  sugar  than  in  woman's  milk.  Moreover,  in 
modifying  cow's  milk  for  infant  feeding  not  only  must  these  differences 


398  THE  PUERPERIUM  AXD  ITS  MANAGEMENT 

be  considered,  but  also  the  presence  of  bacteria  in  cow's  milk;  its  acidity 
and  the  fact  that  the  fats  and  the  protein  of  cow's  milk  are  more  difficult 
for  the  baby  to  digest  than  are  those  of  woman's  milk. 

The  individual  modifications  will  now  be  considered. 

Fat. — The  amount  of  fat  which  a  normal  baby  can  digest  varies  from 
1  to  4  per  cent,  and  the  usual  rule  of  modification  is  to  start  a  baby  on 
a  dilution  of  cow's  milk  containing  about  1  per  cent,  of  fat  and  very  grad- 
ually increase  it  until  it  is  able  to  digest  4  per  cent,  of  fat  which  probably 
will  not  be  for  several  months. 

Sugar. — ^The  modification  of  cow's  milk  to  correspond  with  woman's 
milk,  so  far  as  sugar  is  concerned,  consists  simply  in  the  addition  of 
sugar  of  milk  until  the  required  percentage  is  obtained. 

Protein. — ^For  a  long  time  protein  was  considered  the  ingredient  of 
cow's  milk  which  was  the  most  difficult  for  the  baby  to  digest.  Riper 
experience  showed  that  the  healthy  child  usually  had  more  difficulty 
in  digesting  fat  than  protein  and  in  certain  cases  of  disordered  digestion 
any  of  the  ingredients  of  milk  may  cause  trouble.  Usually  in  the  first 
week  the  baby  will  easily  digest  0.5  per  cent,  of  protein,  1  per  cent,  at  three 
weeks  and  2  per  cent,  at  four  months.  Protein  is  important  for  the 
nutrition  and  general  development  of  the  child  and  should  not  be  kept  at 
a  low  percentage  too  long.  The  usual  modification  of  the  protein  of  cow's 
milk  to  fit  it  for  infant  feeding  is  simply  dilution,  although  if  the  baby 
has  difficulty  in  digesting  it  the  milk  can  be  peptonized. 

Salts. — When  cow's  milk  has  been  diluted  so  that  the  percentage  of 
protein  is  about  right  to  give  the  baby,  it  is  found  that  the  amount  of 
total  salts  approximates  that  in  woman's  milk.  This  is  seen  in  the  follow- 
ing table  from  Holt: 

Cow's  milk 
Protein    .      .      .      .3.50 
Inorganic  salts    .      .      0.75 

The  dilution  of  the  milk  which  gives  a  suitable  percentage  of  fat  and 
protein  so  nearly  adjusts  the  inorganic  salts  to  the  baby's  needs  that 
they  can  usually  be  disregarded  in  preparing  a  formula  for  the  baby's 
food. 

Bacteria. — The  presence  of  bacteria  in  cow's  milk  and  the  fact  that 
there  must  be  a  relatively  small  number  in  milk  suitable  for  infant  feed- 
ing has  already  been  mentioned.  The  destruction  of  these  bacteria  in 
modified  milk  will  be  discussed  later  under  the  head  of  Pasteurization. 

Reaction. — ^As  cow's  milk  is  acid  in  reaction  rather  than  amphoteric 
to  litmus  paper,  as  is  woman's  milk,  it  follows  that  this  excessive  acidity 
must  be  overcome.  This  is  usually  accomplished  by  adding  5  per  cent, 
of  lime-water,  or  1  ounce  to  each  20  ounces  of  food,  although  bicarbonate 
of  soda  may  be  used. 

Home  Modification. — In  the  home  modification  of  cow's  milk  for  infant 
feeding,  aside  from  knowing  that  the  milk  is  clean  from  healthy  cows  and 
that  the  milk  was  cooled  at  once  and  kept  cool  until  used,  it  is  important 
to  know  the  percentage  of  fat  in  the  milk  used.     In  preparing  the  food 


DUuted 
once. 

Diluted 
twice. 

Diluted 
3  times. 

Diluted 
4  times. 

1.75 
0..37 

1.16 
0.25 

0.87 
0.18 

0.70 
0.15 

MODIFICATION  OF  COWS  MILK  399 

for  the  young  baby,  milk  with  considerable  cream  in  it  is  desired.  Cream 
is  but  milk  in  which  a  large  percentage  of  the  fat  has  accumulated  by 
rising.  Thus  in  the  ordinary  dairy  of  the  farm  where  the  night's  milking 
is  placed  in  pans  and  allowed  to  stand  until  morning  when  the  cream  is 
skimmed  from  the  top  of  the  pan,  the  milk  as  put  into  the  pan  has  the 
average  composition  of: 

Fat,  4  per  cent. 

Sugar,  4.5  per  cent. 

Protein,  3.5  per  cent.,  but  the  cream  which  is  skimmed  off  in  the 
morning  has  most  of  the  fat  in  it  and  its  composition  is: 

Fat,  16  per  cent. 

Sugar,  4.5  per  cent. 

Protein,  3.5  per  cent. 

In  other  words,  cream  is  nothing  but  fat  milk.  Cream  obtained  in 
this  way  is  called  gravity  cream,  as  distinguished  from  cream  separated 
from  the  milk  by  a  centrifugal  machine,  which  is  called  centrifugal  cream. 
At  the  present  day  most  of  the  cream  in  the  market  is  centrifugal  cream 
as  it  can  be  obtained  and  delivered  twenty-four  to  thirty-six  hours  earlier 
than  by  the  gravity  process. 

It  is  well  for  the  obstetrician  to  remember,  in  cases  of  emergency  in 
the  country,  that  the  gravity  cream  on  the  top  of  a  pan  of  milk  which 
has  stood  for  four  or  more  hours  is  approximately  milk  with  16  per  cent. 
fat. 

For  infant  feeding,  however,  it  is  the  custom  to  use  milk  from  a  quart 
milk  bottle  which  has  been  filled  at  the  dairy,  cooled  at  once  and  kept 
cool  until  used.  This  bottle  of  milk  if  kept  quiet  after  filling  will  in  four 
hours  have  most  of  the  fat  at  the  top.  If  it  has  been  transported  to  a 
distance  it  should  be  allowed  to  stand  for  two  hours  in  the  refrigerator 
to  allow  the  cream  to  separate  again. 

As  it  is  often  necessary  in  infant  feeding  to  have  milk  with  different 
percentages  of  fat,  it  is  important  to  know  the  approximate  amount  of 
fat  in  the  milk  at  different  heights  in  the  bottle  which  has  stood  for  four 
hours  or  more,  and  how  milk  with  different  percentages  of  fat  may  be 
obtained.  As  the  cream  rises  the  milk  at  the  top  of  the  bottle  contains 
a  very  high  percentage  of  fat,  perhaps  20  per  cent.,  which  rapidly  decreases 
as  you  descend  until  at  one-eighth  of  the  way  down  it  is  only  2  per  cent.,  a 
quarter  of  the  way  down  only  1  per  cent.,  and  below  perhaps  only  0.5  per 
cent.  If  the  bottle  is  thoroughly  shaken  the  percentage  of  fat  will  be  that 
of  the  average,  i.  e.,  4  per  cent.  In  baby  feeding  it  is  found  that  milk 
containing  7  per  cent,  of  fat  is  sufficiently  rich,  although  it  is  often  neces- 
sary to  have  a  milk  with  a  lower  percentage.  The  problem  of  the  obstet- 
rician is  to  obtain  milk  with  7  per  cent,  of  fat  and  with  percentages  lower 
than  this.  This  is  done  by  taking  the  top  milk  down  to  different  levels 
from  a  quart  bottle  which  has  stood  until  the  cream  has  risen  to  the  top, 
thus: 

Sixteen  ounces  from  top  of  quart  bottle 7  per  cent. 

Twenty  ounces  from  top  of  quart  bottle 6  " 

Twenty-four  ounces  from  top  of  quart  bottle 5  " 

Whole  bottle  shaken 4  " 


400  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

For  the  feeding  of  a  healthy  baby  during  the  first  month  of  its  life, 
and  this  is  the  function  of  the  obstetrician,  it  is  found  that  7  per  cent, 
milk  is  usually  the  most  satisfactory,  and  this  is  best  obtained  by  dipping 
as  with  a  Chapin  dipper  the  upper  half  from  a  quart  bottle  of  milk  in 
which  the  cream  has  risen  to  the  top  (in  order  to  prevent  running  over 
when  inserted  the  first  dipper  should  be  filled  with  a  spoon).  The  for- 
mula of  this  milk  averages: 

Fat      .      .      7  per  cent.       Sugar  4.5  per  cent.       Protein      .      .      3.5  per  cent. 

It  may  also  be  obtained  in  an  emergency  by  taking  one  part  of  gravity 
cream  standing  on  a  pan  of  milk  which  approximately  would  be: 


and  three  parts  of  ordinary  milk 


Fat. 

Sugar. 

Protein. 

16 

4.5 

3.5 

'  4 

4.5 

3.5 

4 

4.5 

3.5 

^  4 

4.5 

3.5 

28 

18.0 

14.0 

7 

4.5 

3.5 

which  would  give  as  an  average 

Having  obtained  7  per  cent,  top  milk  the  next  problem  is  the  dilution 
of  this  milk  to  suit  the  age,  but  more  important,  to  suit  the  digestion  of 
the  individual  baby.  No  baby's  digestion  is  determined  by  mathematics, 
and  no  milk  formula,  however  carefully  worked  out,  is  bound  to  agree 
with  every  baby  of  the  same  age  and  weight.  There  is  one  principle, 
however,  which  should  guide  the  obstetrician. 

The  baby  should  be  started  on  a  food  so  weak  that  almost  any  baby 
could  digest  it  and  then  the  strength  and  amount  of  the  food  should  be 
gradually  increased  as  the  baby  shows  its  ability  to  digest  more,  care 
being  taken  not  to  increase  so  rapidly  in  either  strength  or  amount  as  to 
upset  the  digestion  or  cause  dilatation  of  its  stomach.  A  baby  whose 
food  is  increased  too  rapidly  in  either  strength  or  amount  is  apt  to  be  so 
upset  as  to  require  a  considerable  period  of  patient  effort  on  the  part 
of  those  in  charge  before  the  regular  gain  is  established. 

If  the  baby  seems  well,  sleeps  well,  has  normal  stools  and  gains  a  little 
each  week  it  is  usually  wise  to  be  satisfied  rather  than  to  attempt  to 
surpass  the  neighbor's  baby  in  weight.  In  preparing  the  baby's  food 
it  is  usually  most  convenient  to  make  the  amount  20  ounces  or  multiples 
thereof. 

The  amount  of  lime-water  needed  to  produce  the  required  alkalinity 
is  1  ounce  in  20  ounces  of  food,  or  5  per  cent.,  and  the  amount 
of  milk-sugar  which  is  required  to  be  added  is  usually  1  ounce  in  20 
ounces  of  food,  or  5  per  cent.  For  these  reasons,  among  others,  20 
ounces  is  the  amount  of  food  usually  first  prepared.  Now,  how  many 
ounces  of  this  7  per  cent,  top  milk  shall  be  used  in  this  20  ounces  of  food? 
As  a  rule  a  healthy  baby  of  average  size  can  easily  digest  on  the  second 
day  milk  composed  of  3  ounces  of  the  7  per  cent,  top  milk  with  1  ounce 
of  milk-sugar  and  1  ounce  of  lime-water  and  diluent  up  to  20  ounces.    In 


MODIFICATION  OF  COWS  MILK  401 

order  to  understand  the  percentage  of  fat,  sugar  and  protein  the  baby  is 
getting  the  following  formulae  should  be  studied : 

Fat.  Sugar.  Protein. 

7  per  cent,  top  milk 7  4.5  3.5 

If  1  ounce  of  this  milk  is  taken  and  diluted  up  to  20  ounces  the  result 
would  be  as  follows: 

Fat.  Sugar.  Protein, 

20)7.00  4.50  3.50 


0.35  0.22  0.17 


If  1  ounce  of  sugar  is  added  to  the  20  ounces  it  would  be  5  per  cent., 
and  would  give 

Fat.  Sugar.  Protein. 

0.35  0.22  0.17 

5.00 


0.35  5.22  0.17 


This  is  spoken  of  as  1  in  20  milk  from  7  per  cent,  top  milk. 
If  3  ounces  of  7  per  cent,  top  milk  are  taken  and  diluted  up  to  20 
ounces  the  result  would  be  three  times  the 


Fat. 

Sugar, 

Protein. 

0.35 

0.22 

0.17 

Fat. 

Sugar. 

Protein. 

1.05 

0.66 

0.51 

or 


If  1  ounce  of  sugar  of  milk  is  added  to  the  20  ounces,  or  5  per  cent., 
the  result  would  be 

Fat.  Sugar.  Protein. 

5.00 


1.05  5.66  0.51 


This  is  a  food  which  most  babies  can  digest  on  the  second  or  third  day. 

This  is  called  3  in  20  from  7  per  cent,  top  milk.  In  the  same  way  by 
taking  4  ounces  of  the  7  per  cent,  top  milk  and  diluting  up  to  20  ounces 
and  adding  1  ounce,  or  5  per  cent.,  of  milk-sugar  the  result  would  be 

Fat.  Sugar.  Protein. 

1.4  5.88  0.68 

and  would  be  called  4  in  20  milk  from  7  per  cent,  top  milk. 
Obtained  in  a  similar  way  5  in  20  milk  would  be 

Fat.  Sugar.  Protein. 

1.75  6.10  0.85 

6  in  20  milk  would  be .      2.10  6.32  1.02 

7  in  20  milk  would  be 2.45  6.54  1.19 

As  already  indicated  it  is  impossible  to  frame  a  schedule  of  strengths 
of  milk  which  all  babies  can  follow  and  an  average  can  only  be  suggested. 
Usually  a  healthy  baby  will  be  able  to  digest  a  4  in  20  milk  by  the 
26 


402  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

fourth  or  fifth  day;  a  5  in  20  or  a  6  in  20  milk  in  the  second  week  and  a 
7  in  20  milk  in  the  fourth  week.  As  a  rule  the  strength  of  the  food  is  not 
increased  unless  the  stools  show^  that  the  digestion  is  good,  but  the  baby 
is  not  satisfied. 

The  Amount  of  Food  Allowed  at  Each  Feeding.— This  as  well  as  the 
strength  of  food  varies  with  the  individual  child  and  no  positive  schedule 
can  be  given. 

The  following  schedule  is  intended  merely  to  suggest  the  approximate 
amounts  allowable  at  the  different  stages: 

First  week 1     to  l|  ounces. 

Second  and  third  weeks 1^  to  3 

Fourth  and  fifth  weeks 25  to  4 

Sixth  to  ninth  week         3    to  5 

Third  to  fifth  month 4    to  6 

Fifth  to  ninth  month 5    to  7 

Ninth  to  twelfth  month 6    to  9 

The  Diluent. — The  author's  experience  in  feeding  babies  at  the  Sloane 
Hospital  leads  him  to  believe  that  many  babies,  even  during  the  first 
month  of  life,  are  more  comfortable,  have  more  normal  stools,  and  gain 
faster  if  the  diluent  of  the  top  milk  is  a  w^eak  barley-water  rather  than 
plain  water.  The  barley-water  used  is  made  as  follows:  A  table- 
spoonful  of  barley  flour  is  added  to  a  quart  of  water  and  cooked  for 
twenty  minutes. 

Instruction  in  Food  Preparation. — Realizing  the  difficulty  in  instructing 
the  laity,  especially  the  ignorant  women  of  a  hospital  ward  service,  in 
percentage  feeding,  the  author  has  arranged  an  apparatus  which,  at  a 
nominal  cost,  can  be  placed  in  the  hands  of  women  leaving  the  hospital, 
and  which  will  enable  them,  after  having  been  once  shown,  to  prepare 
a  proper  food  for  their  baby,  even  should  they  know  nothing  of  percen- 
tage feeding.  This  apparatus  is  called  the  Sloane  Maternity  Milk  Set, 
and  the  description  accompanying  the  set  is  as  follows: 


THE    SLOANE   MATERNITY   MILK    SET. 

(Arranged  by  the  Author.) 

The  set  consists  of  a  measuring  glass  holding  twenty  ounces  (see  Fig. 
282),  and  a  metal  dipper  (called  the  Chapin  dipper)  holding  one  fluid 
ounce  (see  Fig.  283). 

Directions  for  Use. — Get  a  quart  bottle  of  good  milk  and  let  it  stand  on 
ice  or  in  a  cool  place  for  an  hour  so  that  the  cream  will  show  at  the  top 
of  the  bottle. 

Take  sixteen  dipperfuls  from  the  top  of  the  bottle,  filling  the  first  dipper 
with  a  clean  spoon  and  taking  the  remaining  fifteen  dipperfuls  by  dipping 
carefully  from  the  bottle. 

These  sixteen  dipperfuls  (called  top  milk)  are  to  be  mixed  in  a  clean 
pitcher  and  from  the  milk  thus  mixed  the  baby's  food  is  prepared. 

In  using  this  milk  set,  Avhatever  strength  of  food  is  desired,  the  sugar 


THE  SLOANE  MATERNITY  MILK  SET 


403 


Fig.  282 


Fig.  283 


and  the  lime-water  are  always  the  same :  one  ounce  of  milk-sugar  (or  a  half- 
ounce  of  granulated  sugar)  and  one  ounce  (one  dipperful)  of  lime-water. 

The  quantity  of  food  made  by  filling  the  glass  once  is  always  the  same 
— twenty  ounces.  The  strength  of  the  food  varies  with  the  number  of 
dipperfuls  of  top  milk  used. 

Preparation  of  the  Food. — First. — Into  the  measuring  glass  pour  milk- 
sugar  up  to  the  line  marked  1  ounce  milk-sugar,  or  granulated  sugar  up 
to  the  line  marked  half-ounce  granulated  sugar. 

Secoxd. — Add  one  dipperful  of  lime-water  and  mix  by  shaking  the 
glass. 

Thike. — Add  the  required  number  of  dipperfuls  of  top  milk  according 
to  the  age  of  the  baby,  as  explained  below. 

FoFRTH. — Fill  the  measuring  glass  up  to  the  line  marked  20  ounces 
of  food,  with  water,  either  plain  or  barley-water. 

During  the  first  month  it  is  usually 
better  to  use  plain  boiled  water,  after  that 
barley-water. 

Strength  of  Food  for  Different  Months. — 
First  day:  Give  no  milk;  put  in  milk-sugar 
to  mark,  then  fill  with  boiled  water. 

Second  day:  Add  two  dipperfuls  of  top 
milk. 

Third  day: 
milk. 

Fourth  day 
milk. 

Fifth  to  tenth 
of  top  milk. 

Tenth  to  thirtieth  day:  Add  six  dipper 
fuls  of  top  milk. 

One  month   to  two  months:   Add 
dipperfuls  of  top  milk. 

Two  months  to  four  months:  Add  eight  dipperfuls  of  top  milk. 

Four  months  to  nine  months:  Add  ten  dipperfuls  of  top  milk. 

When  the  baby  needs  more  than  20  ounces  in  the  twenty-four  hours, 
fill  the  measuring  glass  twice  instead  of  once  before  putting  the  food  into 
the  baby's  bottle. 

After  nine  months  the  food  is  prepared  by  shaking  the  quart  bottle  of 
milk  when  first  obtained  and  using  the  plain  mixed  milk. 

After  preparing  the  food  put  it  (especially  in  hot  weather)  on  the  stove 
and  heat  it  until  it  simmers.  It  is  then  ready  to  be  placed  iii  the  baby's 
bottles  which  have  been  thoroughly  washed  in  hot  soapsuds  and  rinsed. 

The  above  directions  are  given  for  an  average  healthy  baby.  A  frail 
baby,  or  one  whose  weight  is  below  the  average,  wUl  need  to  have  the 
strength  of  food  increased  more  slowly.,  A  very  strong,  healthy  baby  may 
have  the  strength  of  the  food  increased  more  rapidly.  If  the  stronger 
food  does  not  seem  to  agree  with  the  baby  decrease  the  number  of  dipper- 
fuls of  milk  used. 


Add  three  dipperfuls  of  top 
Add  four  dipperfuls  of  top 
day:   Add  five  dipperfuls 
ipper- 
seven 


Figs 


282     and    283.  —  Sloane 
maternity  milk  set. 


404 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


B>'  increasing  or  decreasing  the  number  of  dipperfuls  of  milk  the  food 
can  usually  be  adjusted  to  the  child's  digestion. 

Amount  of  Food  at  Each   Feeding  for  Different  Ages. — First  week, 
1-1 1  ounces. 

Second  and  third  Aveeks,  l|-3  ounces. 

Fourth  and  fifth  weeks,  2^-4  ounces. 

Sixth  to  ninth  week,  3-5  ounces. 

Third  to  fifth  month,  4-6  ounces. 

Fifth  to  ninth  month,  5-7  ounces. 

Ninth  to  twelfth  month,  6-9  ounces. 

Bottles. — The  milk  having  been  modified  to 
suit  the  digestion  of  the  baby  and  the  number 
of  feedings  and  the  amount  to  be  given  at  each 
having  been  decided  upon,  the  next  question  is, 
what  sort  of  bottles  shall  be  used  in  giving  the 
food  to  the  baby?  The  best  bottles  are  those 
which  can  be  most  readily  cleaned.  Cylindrical 
bottles  so  shaped  that  a  straight  stick  like  a 
lead-pencil  can  reach  each  part  of  the  inside  (see 
Fig.  284)  meet  the  indication. 

Bottles  which  are  graduated  on  the  side  are  a 
convenience.  As  many  bottles  should  be  used  as 
the  baby  has  feedings  in  the  twenty-four  hours,  as 
the  food  for  the  twenty-four  hours  should  be  made 
up  at  once  and  apportioned  to  the  different  bottles, 
which  should  be  placed  in  the  ice-box  until  needed. 


Fig.  284 


Fig.  285. — Auticolic  uipple. 


The  bottles  after  using  should  be  rinsed  with  cold  water  then  washed 
with  hot  soapsuds  and  a  little  brush,  and  once  a  day  they  should  be  put 
in  cold  water  and  boiled  for  a  half-hour,  taken  out  and  stood  bottom  up 
until  needed. 

Nipples. — The  nipple  which  can  be  applied  directly  to  the  bottle  is 
the  best.  The  nipple  connected  to  the  bottle  by  a  small  rubber  tubing 
is  almost  impossible  to  keep  clean  and  should  be  discarded.  The  nipple 
with  a  bulbous  end  called  the  "anticolic"  nipple,  as  seen  in  Fig.  285,  is 
a  satisfactory  one. 

The  size  of  the  hole  in  the  nipple  is  a  matter  of  importance.  It  should 
be  large  enough  when  the  nipple  is  filled  with  water  and  held  tip  down- 


STERILIZATION  OF  MILK  BY  PASTEURIZATION  405 

ward  to  allow  the  water  to  escape  drop  by  drop  but  not  large  enough  to 
let  it  run  in  a  stream.  The  rubber  nipples  should  be  washed  with  cold 
water,  then  in  hot  soapsuds,  and  once  a  day  boiled  or  steam  sterilized. 
They  should  then  only  be  handled  with  clean  hands. 

Destruction  of  the  Bacteria  in  Milk. — Knowing  that  cow's  milk  with 
the  ordinary  methods  of  handling  contains  enormous  numbers  of  bacteria, 
and  often  pathogenic  bacteria,  it  seems  natural  that  the  question  of  their 
destruction  should  have  forced  itself  upon  the  profession.  A  number 
of  years  ago  Jacobi,  of  New  York,  advocated  boiling  milk  in  small  bottles 
for  infant  feeding.  This  was  still  further  popularized  by  Soxhlet,  in  1886, 
and  gradually  came  into  general  use.  This  process  of  heating  milk  to 
212°  F.,  and  maintaining  it  for  one  to  one  and  a  half  hours,  received  the 
name  of  sterilization  and  was  productive  of  great  good  in  checking  the 
spread  of  tuberculosis  and  diseases  which  may  be  carried  through  the 
medium  of  milk,  especially  at  a  time  prior  to  the  modern  endeavors  to 
obtain  clean  milk  through  healthy  cows,  clean  stables,  clean  milkers  and 
clean  receptacles. 

It  was  soon  found,  however,  that  sterilized  milk  had  disadvantages, 
and  that  even  this  degree  of  heat  did  not  make  the  milk  safe  for  very 
long,  as  the  spores  were  not  destroyed  and  at  the  temperature  of  the  room 
bacteria  would  soon  develop  again.  INIoreover,  the  taste  of  the  milk 
was  altered  by  sterilization.  It  was  constipating  and  in  a  certain  number 
of  cases  it  produced  scurvy.  This  led  to  experiments  along  the  line  of 
raising  the  milk  to  a  lesser  degree  of  heat  than  212°  F.  It  has  been 
found,  chiefly  through  the  work  of  Freeman  of  New  York,  that  raising 
the  temperature  of  milk  to  140°  F.  and  maintaining  it  for  forty  minutes 
is  sufficient  to  kill  the  bacilli  of  tuberculosis,  typhoid  fever,  diphtheria, 
and  from  98  to  99  per  cent,  of  all  other  bacteria  in  milk.  In  addition, 
nearly  all  the  objectionable  features  associated  with  sterilized  milk  are 
eliminated.  The  spores,  however,  are  not  killed  and  the  milk  after  pas- 
teurization must  be  cooled  rapidly  and  kept  cool  until  just  before  using. 
As  a  rule  pasteurized  milk  should  not  be  kept  over  twenty-four  hours. 

Dr.  Rowland  G.  Freeman,  of  New  York,  has  devised  a  very  simple 
apparatus  for  pasteurizing  milk  for  infant  feeding,  and  his  instructions 
for  its  use  are  here  given : 


INSTRUCTIONS  FOR  USING  DR.  FREEMAN'S  APPARATUS  FOR 

LOW-TEMPERATURE   STERILIZATION   OF  MILK 

BY   PASTEURIZATION. 

Pasteurization  of  milk  consists  in  heating  it  rapidly  to  about  140°  F., 
retaining  it  at  that  temperature  a  definite  time  and  then  cooling  it  rapidly 
to  below  60°  F.  The  apparatus  is  designed  to  accomplish  this  purpose. 
It  subjects  the  milk  to  a  temperature  of  about  140°  F.  for  40  minutes. 

The  apparatus  consists  of  a  pail  for  water  and  a  receptacle  for  the 
bottles  of  milk. 

The  yail  is  a  simple  pail  with  cover.    Extending  around  the  pail  is  a 


406 


THE  PUERPERWM  AND  ITS  MANAGEMENT 


groove  for  indicating  the  level  to  which  the  pail  is  to  be  filled  with  water. 
Inside  the  pail  are  three  supports  (Fig.  286,  C)  for  holding  the  receptacle. 
The  receptacle  for  the  bottles  of  milk  consists  of  a  number  of  hollow 
cylinders  fastened  together.  Surrounding  and  binding  together  the  group 
of  cylinders  is  a  wire  (.4).  It  is  this  wire  {A)  which  rests  on  the  support 
(C)  when  the  milk  is  being  heated  (Fig.  286).  Below  the  wire  {A)  are 
three  short  wires  (B).  These  wires  (B)  rest  on  supports  (C)  when  the 
receptacle  is  raised  for  cooling  (Fig.  287). 

1 .  Fill  the  pail  to  the  level  of  the  groove  with  water,  cover  it  and  put- 
it  on  the  stove  to  boil,  the  receptacle  for  the  bottles  having  been  left  out. 

2.  Fill  the  body  of  each  bottle  with  milk  or  some  modification  of  milk 
in  proper  proportion  for  feeding;  stopper  with  a  wad  of  cotton  batting 
and  ])ut  in  a  refrigerator.  If  all  the  bottles  which  the  receptacle  holds 
are  not  needed,  fill  the  remaining  cylinders  with  cold  Avater.  Each  space 
in  the  receptacle  must  be  filled. 


Fig.  286. — Freeman  pasteurizer. 


Fig.  287. — Freeman  pasteurizer. 
Receptacle  raised  for  cooling. 


3.  When  the  water  in  the  pail  on  the  stove  boils  thoroughly,  take  the 
bottles  of  milk  from  the  refrigerator  and  put  them  in  the  spaces  for  them 
in  the  receptacle. 

4.  Pour  cold  water  into  each  of  these  spaces  so  as  to  surround  the 
body  of  the  bottle. 

5.  Take  the  pail  of  boiling  water  from  the  stove  and  put  it  on  a  table 
or  mat.  Do  not  put  it  on  metal  or  stone.  Be  sure  that  the  pail  is  still 
filled  exactly  to  the  level  of  the  groove  and  that  the  water  is  boiling 
vigorously. 

6.  Set  the  receptacle  containing  the  bottles  of  milk  into  the  pail  of 
boiling  water  so  that  the  wire  (.4)  will  rest  on  the  support  (C),  cover  the 
pail  quickly  and  let  it  stand  one  hour.  During  this  period  the  pail  must 
not  be  on  the  stove  and  the  cover  must  not  be  removed. 

7.  Now  uncover  the  pail  and  lift  the  receptacle  and  turn  it  so  that  the 
wire  (B)  will  rest  on  the  support  (C),  thus  elevating  the  top  of  the  receptacle 
above  that  of  the  pail.  Put  the  pail,  containing  the  receptacle  elevated 
in  this  manner,  in  a  basin  under  a  faucet  to  which  a  rubber  pipe  may  be 
attached  connecting  it  with  the  pail  (Fig.  287).    The  water  will  overflow 


STERILIZATION  OF  MILK  BY  PASTEURIZATION  407 

from  the  pail  into  the  basin.    Or  the  pail  may  be  stood  under  a  pump, 
fresh  cold  water  being  pumped  into  it  every  few  minutes. 

The  above-described  method  of  cooling  is  the  best.  When,  however, 
it  is  not  possible  to  cool  the  milk  in  this  way,  the  cooling  may  be  accom- 
plished by  placing  the  receptacle  containing  the  bottles  of  milk  in  iced 
water,  or  by  simply  standing  the  bottles  on  wood  in  a  refrigerator. 

8.  To  warm  the  milk  for  use  put  the  bottle  containing  it  in  a  vessel 
of  cold  water  on  a  stove  and  leave  it  until  it  is  warm.  Use  a  fresh  bottle 
for  each  feeding. 

9.  Wash  the  bottles  thoroughly  after  using,  and  once  a  day  put  all  the 
empty  bottles  in  a  kettle  of  cold  water  on  the  stove  and  let  this  water 
boil  for  an  hour.  The  bottles  should  then  be  taken  out  and  stood  bottom 
up  until  used. 

Milk  sterilized  by  this  apparatus  may  be  used  for  food  during  the 
following  twenty-four  hours. 

The  pasteurizer  is  made  in  two  sizes,  one  holding  ten  6-ounce  bottles, 
the  other  seven  8-ounce  bottles. 

Never  use  6-ounce  bottles  in  the  8-ounce  receptacle. 

Never  use  8-ounce  bottles  in  the  6-ounce  receptacle. 

Pasteurized  Milk  or  Raw  Milk,  Which? — There  is  no  denying  the  fact 
that  if  it  was  certain  that  the  milk  was  clean  in  the  sense  that  it  came 
from  healthy  cows,  that  the  strictest  precautions  as  to  cleanliness  in  the 
stables,  the  dairy  and  among  the  dairymen  had  been  observed,  clean  raw 
milk  would  be  better  than  pasteurized  milk.  In  the  warm  weather 
especially  the  milk  in  the  cities  has  required  so  long  a  time  in  transporta- 
tion (twenty-four  to  forty-eight  hours)  and  the  milk  in  the  country  is 
so  apt  to  come  from  uncertain  dairies  that  the  only  safe  milk  for  the 
baby  is  pasteurized  milk.  The  importance  of  heating  milk  in  summer, 
in  order  to  keep  it,  has  long  been  recognized  by  housewives  who  for 
years  have  been  in  the  habit  of  "scalding"  milk,  which  generally  means 
setting  the  vessel  containing  the  milk  on  the  back  of  the  range  until  it 
"simmers."  It  is  found  that  milk  thus  treated  has  been  raised  to  about 
the  temperature  to  which  so-called  pasteurized  milk  is  now  raised. 

Furthermore,  an  investigation  of  the  Health  Board  of  New  York  City 
as  to  the  condition  of  the  milk  in  the  tenements,  found  that  the  laity  had 
become  so  well  educated  as  to  the  importance  of  heating  milk  before 
using  it  for  food  for  the  baby  that  in  a  large  majority  of  the  families 
some  method  of  heating  the  milk  was  employed  before  the  baby  was  fed. 

This  fact  should  be  borne  in  mind :  If  there  is  any  uncertainty  about 
the  health  of  the  cows  or  the  hygiene  of  the  dairy,  and  especially  during 
any  epidemic  of  diphtheria,  typhoid  or  scarlet  fever,  the  only  safe  milk 
is  that  which  has  been  heated. 

Peptonized  Milk. — For  babies  having  difficulty  in  digesting  the  protein 
of  cow's  milk,  a  partial  predigestion  by  an  extract  derived  from  the  pan- 
creas called  extractum  pancreatis,  acting  in  an  alkaline  medium,  as  with 
bicarbonate  of  soda  added,  is  often  of  very  great  assistance.  Many 
babies  who  are  not  gaining  on  a  given  formula  of  milk  will  often  start 
at  once  to  gain  as  soon  as  the  milk  is  peptonized.    Moreover,  when  a  baby 


40S 


THE  PUERPERIUM  AND  ITS  MANAGEMENT 


can  (li<i;('st  a  very  weak  formula  of  milk,  and  for  the  proper  development 
of  the  ehild  a  stronjier  formula  is  desired,  this  ean  often  he  digested  when 
peptonized.  Thus  peptonizing  the  milk  until  the  baby  can  easily  digest 
the  food  which  is  natural  for  its  age  and  weight  has  often  a  distinct 
advantage.  The  most  convenient  method  of  ])eptonizing  the  food  is  by 
means  of  the  peptonizing  tubes,  which  are  on  the  market,  which  contain 
the  extractum  pancreatis  and  the  alkali  in  the  same  tube.  One  of  the 
tubes  should  be  distributed  among  the  different  bottles  prepared  for  the 
twenty-four  hours'  food  as  follows:  If  there  are  eight  bottles  prepared 
for  the  eight  feedings,  twenty  minutes  before  feeding  time  one  of  the 
bottles  should  be  taken  from  the  ice-box,  the  cotton  stopper  removed, 
one-eighth  of  the  contents  of  the  peptonizing  tube  added  to  the  milk, 
the  stopper  replaced  and  the  bottle  stood  in  warm  water  for  the  twenty 
minutes.     It  is  then  ready  to  be  given  to  the  baby. 

Laboratory  Milk. — Through  the  initiative  of  the  Walker-Gordon  Co. 
there  have  been  established  since  1892-93  in  Boston,  New  York  and  many 
other  large  cities,  milk  laboratories  where  physicians  can  obtain  by  pre- 
scription almost  any  formula  of  milk  for  infant  feeding.  The  Walker- 
Gordon  Co.  have  their  own  farm  where  the  milk  is  obtained  under  most 
perfect  hygienic  conditions  as  regards  cows,  dairy  and  dairymen,  and  the 
milk  is  under  the  constant  supervision  of  a  competent  bacteriologist. 

At  the  laboratory  they  have  as  available  factors  with  which  to  fill 
the  different  prescriptions: 

Centrifugal  cream  containing  32  per  cent,  fat; 

Separated  milk  from  which  the  fat  has  been  removed; 

A  20  per  cent,  solution  of  milk-sugar; 

Lime-water. 

With  these  different  factors  a  prescription  for  almost  any  percentage 
of  fat,  sugar  and  protein  can  be  filled  and  by  using  whey  the  percentage 
of  whey,  protein  and  casein  is  varied. 

The  physician  can  thus  order,  as  on  the  blank  given  below,  milk  for 
his  baby  patient  as  he  would  order  drugs  from  a  drug-store,  and  the 
annoyance  of  home  modification  be  avoided. 


Per  cent. 

Remarks. 

Fat 

Milk-sugar    

Number  of  feedings 

Amount  of  each  feeding. 

Protein 

■  Whey 

Casein  

Lime-water   . 

Heat  to 

°  F. 

Diluent    

Ordered  for. 


Date . 


Signature ,  M.D. 

Every  obstetrician,  however,  should  understand  and  be  able  to  instruct 
nurses  and  patients  in  the  home  modification  of  milk. 

The  Feeding  of  Premature  Babies. — For  the  satisfactory  feeding  of 
babies  under  four  and  a  half  pounds  it  is  almost  necessary  to  have  breast 
milk.    Although  great  advances  have  been  made  in  artificial  feeding  and 


THE  FEEDING  OF  PREMATURE  BABIES  409 

occasionally  a  premature  baby  will  live  and  thrive  on  modified  cow's 
milk,  this  experience  is  exceptional  and  an  endeavor  should  always  be 
made  to  secure  a  wet-nurse  if  the  mother  of  the  premature  baby  is  unable 
to  furnish  proper  breast  milk. 

A  great  deal  of  milk  will  not  be  required  for  premature  babies,  as  their 
stomachs  are  small  and  their  digestions  weak.  At  the  Sloane  Hospital 
it  is  the  custom  to  feed  the  incubator  babies  every  two  hours  during  the 
daytime  and  less  frequently  during  the  night,  giving  them  equal  parts 
of  breast  milk  and  5  per  cent,  sugar  solution,  starting  with  5ij  o|  the  mix- 
ture at  each  feeding  and  gradually  increasing  it  to  an  ounce  as  the  baby 
grows  stronger  and  the  interval  between  feedings  is  increased. 

The  premature  baby  is  at  first  unable  to  nurse  directly  from  the  breast, 
hence  the  milk  must  be  drawn  with  a  breast-pump.  If  the  services  of  a 
wet-nurse  have  been  secured  it  is  often  advisable  to  allow  her  to  have  her 
baby  with  her,  as  should  only  the  amount  needed  for  the  premature  baby 
be  taken  from  her  breasts  the  milk  supply  will  soon  diminish  and  perhaps 
disappear.  Furthermore,  it  is  almost  impossible  to  keep  up  the  milk 
supply  in  a  breast  if  the  breast-pump  alone  is  used. 

The  baby  of  the  wet-nurse,  if  healthy  (it  is  specially  important  that  it 
is  free  from  venereal  disease),  may  be  used  not  only  to  maintain  the 
milk  supply  of  its  mother,  but  by  going  occasionally  to  the  breasts  of 
the  mother  of  the  premature  baby  develop  them  so  that  the  wet-nurse 
can  soon  be  dispensed  with. 

At  first  the  premature  baby  is  often  unable  to  suck  its  food  through 
a  rubber  nipple  and  has  to  be  fed  by  means  of  a  medicine  dropper,  but 
as  its  strength  increases,  it  readily  takes  the  nipple;  the  diluent  of  the 
breast  milk  is  reduced;  the  interval  between  feedings  is  increased  to  two 
and  a  half  hours;  it  is  allowed  to  go  to  the  breast  two  or  three  times  a 
day,  and  finally  nurses  entirely  from  the  breast  and  is  taken  out  of  the 
incubator.  A  similar  method  of  feeding  premature  babies  is  followed 
if  their  body  temperature  is  maintained  by  means  of  the  heated  rooms, 
the  electric  pad  or  a  cotton  jacket  and  hot-water  bottles. 

Is  the  Food  Agreeing  with  the  Baby? — ^This  question  is  ever  present  with 
the  one  having  the  responsibility  of  the  care  of  the  baby  during  its  early 
life.  If  the  baby  seems  well  and  happy,  sleeps  well,  has  normal  stools 
and  is  gaining  steadily  in  weight,  the  question  can  be  answered  in  the 
affirmative.  Of  all  the  criteria  of  the  agreement  of  the  food  with  the 
baby  the  stool,  which  represents  the  residue  of  that  food,  is  one  of  the 
best.  For  this  reason  it  is  not  only  important  that  the  practical  obstet- 
rician should  be  familiar  with  the  characteristics  of  a  normal  stool  and 
the  various  departures  from  the  normal  but  should  watch  the  baby's 
stool  from  day  to  day  and  thus  keep  informed  of  this  expression  of  its 
digestion. 

Stools. — During  the  first  two  days  of  life,  before  the  milk  is  secreted 
in  the  mother's  breasts,  the  stools  of  the  baby  consist  of  the  black,  tarry 
meconium  which  has  been  accumulating  during  fetal  life  and  which  may 
be  seen  discharged  at  the  time  of  birth,  especially  should  the  presentation 
be  a  breech. 


410  THE  PUERPERWM  AND  IT.S  MANAGEMENT 

The  normal  stool  of  the  baby  after  the  milk  secretion  is  well  established 
in  the  mother's  breast  is  bright  yellow  in  color,  smooth  in  consistency, 
and  without  appreciable  odor. 

Various  departures  from  this  smooth,  yellow  consistency  may  occur 
in  the  baby's  stool  without  markedly  affecting  the  baby's  well-being. 
Sometimes  a  change  in  tiie  weather  or  a  little  overfatigue  of  the  mother 
will  in  some  way  cause  such  a  change  in  her  milk  as  to  give  the  baby  a 
a  green  stool  instead  of  a  bright  yellow  one.  This  change  is  not  thoroughly 
understood  and  it  can  only  be  said  that  it  is  due  to  a  substitution  of  bili- 
verdin  for  bilirubin. 

Lumps  of  undigested  food  usually  called  "curds"  often  appear  in  the 
stool.  Sometimes  most  of  the  stool  is  made  up  of  these  small,  soft, 
yellowish-white  lumps,  often  with  a  little  mucus.  The  lumps  are  usually 
composed  of  fat  and  indicate  an  inability  on  the  part  of  the  baby  to 
digest  all  the  fat  of  its  milk. 

Sometimes  larger,  smooth  lumps  of  a  yellowish-brown  color  appear, 
fewer  and  harder  than  the  fat  curds  just  described.  These  are  usually 
composed  chiefly  of  protein,  perhaps  coated  with  fat.  This  indicates 
a  fault  in  the  digestion  of  the  protein  of  the  food  and  if  they  persist 
may  indicate  a  reduction  in  the  percentage  of  protein  if  the  baby  is 
artificially  fed. 

Loose  green  or  greenish-yellow  stools,  followed  after  a  time  by  the 
appearance  of  mucus,  may  be  due  to  an  excess  of  either  sugar  or  fat. 
Large,  dry,  clay-colored  stools,  with  a  foul  odor,  are  usually  due  to  an 
excess  of  fat. 

In  studying  the  stools  of  a  baby  the  fact  should  be  borne  in  mind  that 
the  stool  of  a  baby  at  its  mother's  breast  may  have  a  character  bad 
enough  to  suggest  a  change  in  the  formula  if  it  was  on  cow's  milk  and  yet 
the  baby  seems  in  general  to  be  doing  well  and  it  is  the  part  of  discretion 
not  to  make  a  change. 

Caloric  Value  of  the  Food. — Li  feeding  a  baby  artificially  it  is  often 
of  value  to  determine  approximately  the  caloric  value  of  the  food  it  is 
recei\'ing  in  order  to  determine  if  it  is  receiving  a  sufficient  number  of 
calories  for  its  weight.  A  baby  at  the  end  of  the  second  week,  weighing 
7  to  8  pounds,  usually  requires  about  300  calories.  Suppose  now  it  is 
taking  8  feedings  of  2|  ounces  each  of  6  in  20  from  7  per  cent,  top  milk. 
That  would  be  20  ounces  of 

Fat.  Sugar.  Protein. 

2.1  6. .32  1.02 

as 

1  gram  of  fat  gives  9.3  calories. 

1  gram  of  sugar  gives  4.1  calories. 

1  gram  of  protein  gives  4.1  calories. 

The  percentage  of  fat  0.021  X  9.3  (caloric  value  of  fat)  =  0.195  calorie 
in  1  gram  of  food. 

The  percentage  of  sugar  0.063  X  4.1  (caloric  value  of  sugar)  =  0.258 
calorie  in  1  gram  of  food. 


RETRACTION  OF   THE  FORESKIN  411 

The  percentage  of  protein  0.01  X  4.1  (caloric  value  of  protein)  =  0.041 
calorie  in  1  gram  of  food.     Total,  0.494. 

1  liter  of  food  =  0.494  X  1000  =  494  calories  in  1  liter  of  food. 

20  ounces  =  |  liter  =  328  calories  in  babies'  food. 

Commercial  Infants  Food. — An  enormous  number  of  these  are  upon  the 
market,  some  advertized  as  substitutes  for  woman's  milk  and  to  be  used 
alone,  such  as  Nestle's  food,  malted  milk,  etc.,  and  others  recommended 
to  be  mixed  with  cow's  milk. 

Although  some  of  these  foods  are  of  value  for  a  short  time,  when  noth- 
ing better  can  be  obtained,  their  prolonged  use  is  very  apt  to  cause  dele- 
terious results,  especially  rickets  and  scurvy.  Thej'  all  have  the  common 
characteristic  of  containing  a  large  percentage  of  carbohydrate  usually 
in  the  form  of  sugar  and  a  low  percentage  of  fat.  Some  of  the  babies  are 
fat  and  may  look  well  in  pictures,  but  they  are  not  strong  babies,  as  shown 
in  later  infant  life.  These  foods  are  occasionally  of  value  when  it  is 
desired  to  discontinue  milk  feeding  for  a  short  time,  but  as  a  rule  if  they 
are  to  be  used  they  should  be  substituted  for  the  carbohydrate  usually 
added  to  cow's  milk  in  its  modification,  and  the  lack  of  fat  should  be 
made  up  by  the  addition  of  cream.  During  the  obstetric  month  there 
is  seldom  any  excuse  for  their  use.  If,  however,  a  woman  taking  an  ocean 
trip  is  unable  to  nurse  her  baby,  they  are  of  marked  value.  In  such  a 
case  the  author  prefers  condensed  milk,  opening  a  fresh  can  each  day 
or  else  having  one  of  the  milk  laboratories  prepare  the  food  for  the  journey, 
pasteurizing  it  and  packing  it  in  ice  before  starting. 

Condensed  milk  diluted  twelve  times  for  a  baby  under  one  month  of 
age  and  from  ten  to  six  times  for  an  older  baby,  has  the  advantage  that 
it  is  sterile  and  the  fats  and  protein  of  cow's  milk  are  reduced  to  a  degree 
that  almost  any  baby  can  digest  and  do  well  on  for  a  short  time. 

TONGUE-TIE. 

One  of  the  minor  operations  which  the  obstetrician  often  has  to  perform 
is  that  for  a  tongue-tie  which  is  so  pronounced  as  to  interfere  with  the 
baby's  nursing.  If  on  inspection  the  frenum  is  found  to  extend  so  far 
forward  as  to  prevent  the  projection  of  the  tongue  beyond  the  gum 
and  causes  a  marked  furrow  in  the  tongue  on  attempts  in  this  direction, 
the  thin  anterior  portion  of  the  frenum  had  better  be  divided.  The 
operation  is  easily  done  with  sharp,  blunt-pointed,  sterile  scissors,  if 
the  opportune  moment  when  the  baby  elevates  the  tongue  and  puts  the 
frenum  on  the  stretch  is  waited  for. 

Two  precautions  are  worthy  of  mention: 

1.  Only  the  thin  anterior  portion  of  the  frenum  should  be  cut. 

2.  If  the  baby  shows  any  tendency  to  the  hemorrhagic  disease  of  the 
newborn  the  operation  had  better  be  postponed  until  the  baby  is  well. 

RETRACTION    OF    THE   FORESKIN— CIRCUMCISION. 

The  retention  of  smegma  within  a  long,  tight  foreskin  of  a  male  baby 
leads  to  an  irritation  of  the  penis  which  not  infrequently  leads  the  child 


412  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

into  subsequent  bad  babits.  For  tbis  reason  tlie  author  advises  routine 
retraction  of  the  foreskin  in  the  second  week  of  infant  hfe  and  repetition 
of  tliis  retraction  by  the  mother  or  nurse  often  enouji;h  to  kee])  the  parts 
c4ean  and  free  from  retention  of  smegma. 

In  the  author's  service  at  the  Sh)ane  Hospital,  where  the  patient 
remains,  as  a  rule,  thirteen  days  after  confinement,  the  routine  procedure 
is  to  retract  the  foreskin  on  the  seventh  and  the  twelfth  days. 

If  the  foreskin  is  very  long  and  tight  and  does  not  retract  easily  after 
one  or  two  retractions,  the  author  in  private  practice  advises  circumcision. 
His  preference  is  to  perform  the  operation  at  about  the  end  of  the  third 
week,  by  wdiich  time  the  baby  has  usually  regained  and  passed  his  birth 
weight  and  is  able  to  endure  a  light  anesthesia.  The  author  usually 
employs  4  sutures  of  catgut,  size  00;  one  at  the  frenum,  one  on  the  dor- 
sum and  one  on  either  side.  After  a  trial  of  different  methods  of  dressing 
the  following  has  been  adopted  as  giving  the  best  results:  Powder  the 
glans  freely  with  sterile  talcum  powder  and  apply  a  large  square  of  sterile 
cotton.  Over  this  apply  the  diaper  as  usual.  When  the  diaper  becomes 
wet  and  soiled,  cleanse  the  parts  with  boric  acid  solution;  dry  them  and 
apply  the  sterile  talcum  powder  and  sterile  cotton  as  before.  The  prin- 
ciple of  the  treatment  is  to  keep  the  parts  clean  and  dry.  Under  this 
procedure  the  baby  seldom  loses  in  weight;  often  gains  as  usual  in  the 
twenty-four  hours  following  the  operation  and  the  wound  is  completely 
healed  at  the  end  of  the  obstetric  month.  Thus  far  the  long,  tight  fore- 
skin of  the  male  baby  has  been  under  discussion.  Of  scarcely  less  impor- 
tance is  the  long,  tight  prepuce  of  the  female  baby.  Although  the  irrita- 
tion is  usually  not  noticed  until  the  child  is  a  little  older,  the  author  has 
seen  little  girls  of  six  months  who  were  almost  constant  masturbators 
when  left  alone,  and  were  only  cured  by  a  "circumcision"  similar  in  detail 
to  that  of  the  male,  removing  the  prepuce  thoroughly. 

OPHTHALMIA    NEONATORUM. 

The  prophylactic  treatment  of  the  eyes  at  birth  has  already  been  dis- 
cussed under  the  Management  of  Normal  Labor  (see  page  337).  It  now 
remains  to  consider  the  actual  treatment  of  ophthalmia  if  infection  of  the 
eye  from  the  birth  canal  escaped  the  prophylaxis  or  if,  as  more  often  hap- 
pens, infection  came  later  from  some  extraneous  source.  As  seen  from 
the  statistics  of  the  Sloane  Hospital,  it  is  seldom  that  after  the  prophyl- 
actic treatment  with  20  per  cent,  argyrol  solution  the  gonococcus  is 
found  in  the  smear  from  the  cases  of  ophthalmia. 

In  a  series  of  10,000  consecutive  deliveries  at  the  Sloane  Hospital  there 
were  237  babies  with  a  purulent  discharge  from  one  or  both  eyes,  giving 
a  frequency  of  1  in  every  42+  cases.  Although  smears  were  taken  in 
all  of  the  cases  the  gonococcus  was  found  in  only  29. 

Day  of  Onset  of  the  Ophthalmia. — The  day  of  the  puerperium  on  which 
the  purulent  discharge  appeared  is  of  interest  as  showing  that  many 
cases  became  infected  subsequent  to  birth.  The  possibilities  of  infec- 
tion of  the  baby's  eyes  in  a  large  obstetric  service  are  numerous  in  spite 


HEMORRHAGIC  DISEASE  OF   THE  NEWBORN  413 

of  all  precautions.  The  mother  in  handling  and  nursing  the  baby  may 
carry  infection  to  the  eyes,  the  baby  itself  may  carry,  through  its  hands, 
infection  to  its  eyes,  or  the  nurse  in  attending  to  several  babies  may  be 
the  medium  of  infection. 

In  the  237  cases  in  the  above  series  the  ophthalmia  began : 

On    1st  day  of  puerperium  in ....  1 

"2d  "  "  10 

"3d  "  "  6 

"     4th  "  "  3 

"     oth  "  "  13 

"     6th  "  "  26 

"     7th  "  " 35 

"     8th  "  "  41 

"     9th  "  "  36 

"  10th  "  "  .29 

"  11th  "  "  20 

"  12th  "  "  11 

"  13th  "  "  4 

"  14th  "  "  1 

"  17th  "  "  1 

237 

Treatment. — The  treatment  followed  by  the  author  at  the  Sloane  Hos- 
pital has  been  frec[uent  irrigations  of  the  eye  from  inner  to  outer  canthus 
with  a  saturated  solution  of  boric  acid ;  the  instillation  of  argyrol,  25  per 
cent,  solution  every  four  hours,  and  the  application  of  cold  boric  acid 
compresses.  The  frequency  of  the  boric  acid  irrigations  should  vary  with 
the  severity  of  the  infection  and  the  amount  of  pus,  the  object  being  to 
keep  the  eye  as  free  from  pus  as  possible.  In  the  severe  cases  with  rapid 
accumulation  of  pus  the  affected  eye  or  eyes  should  be  irrigated  every 
fifteen  to  twenty  minutes.  In  a  few  cases,  in  addition  to  the  arg\Tol, 
an  occasional  instillation  of  1  per  cent,  nitrate  of  silver  solution  has  been 
employed. 

Duration  of  Treatment. — ^The  average  duration  of  treatment  has  been 
seven  and  six-tenths  days.  The  shortest  was  two  days  and  the  longest 
forty-nine  days. 

Results. — Of  the  237  cases  of  ophthalmia  occurring  in  10,000  consecu- 
tive deliveries  235  left  the  hospital  in  good  condition  with  ^"ision  unim- 
paired. One  left  the  hospital  against  advice  and  before  the  treatment 
was  completed.    In  2  cases  there  was  an  opacity  of  a  part  of  one  cornea. 

HEMORRHAGIC   DISEASE    OF    THE    NEWBORN. 

Occasionally  during  the  first  week  of  infant  life,  and  rarely  later, 
spontaneous  hemorrhages  occur  in  different  parts  of  the  body.  These 
hemorrhages  are  from  the  small  bloodvessels;  have  no  apparent  connec- 
tion with  the  delivery  and  are  usually  multiple.  They  may  arise  from 
the  mucous  membrane  of  the  alimentary  canal,  the  blood  appearing 
either  in  the  vomitus  or  in  the  stool;  they  may  come  from  the  navel; 
they  may  appear  subcutaneously  in  different  parts  of  the  body;  there 
may  be  a  hemorrhage  in  the  conjunctivae;  behind  the  eye;  from  the 


414  THE  PUERPERIUM  AND  ITS  MANAGEMENT 

penis;  into  the  meninges  or  in  any  viscus.  The  amount  of  blood  lost  at 
any  one  time  is  usually  not  great,  but  there  is  apt  to  be  a  continuous 
oozing  for  several  hours,  perhaps  days. 

Frequency  and  Etiology. — The  frequency  of  the  disease  seems  to  be 
rather  greater  in  hospital  than  in  private  practice.  In  a  consecutive 
series  of  4000  deliveries  at  the  Sloane  Hospital  there  were  18  cases  of 
hemorrhage  in  the  newborn,  a  frequency  of  1  in  222+.  Of  these  IS  cases, 
14  were  normal  deliveries,  2  were  breech  and  2  were  forceps  deliveries, 
1  being  a  high  forceps  and  1  a  median.  As  to  the  time  of  onset  of  the 
hemorrhage,  in  all  but  3  it  occurred  in  the  first  week.  In  5  it  occurred 
on  the  second  day;  in  6  on  the  third  day;  in  1  on  the  fourth  day;  1  on 
the  fifth  day;  1  on  the  sixth  day;  1  on  the  seventh  day;  1  on  the  eighth 
da>- ;  1  on  the  fifteenth  day ;  and  1  on  the  nineteenth  day.  From  this  it 
will  be  seen  that  the  second  and  third  flay  are  the  most  frequent  times 
of  its  occurrence  and  that  it  seldom  appears  after  the  first  week. 

The  frequency  of  the  source  of  the  bleeding  is  of  interest.  Among  the 
18  cases,  in  2  the  hemorrhage  came  from  the  nose;  in  3  from  the  mouth; 
in  10  from  the  stomach;  in  6  from  the  intestine;  in  3  from  the  navel; 
in  2  from  the  penis;  in  2  it  was  cerebral;  and  in  2  it  was  subcutaneous. 
Of  the  18  mothers,  G  were  primiparse  and  12  multiparte.  But  little 
is  known  concerning  the  exact  etiology  of  the  condition.  In  some  cases 
the  mother  is  syphilitic.  One  of  the  mothers  in  the  author's  series  of  18 
gave  a  positive  Wassermann  reaction.  In  some  cases  the  mother  is  anemic 
and  toxemic,  l)ut  it  is  a  significant  fact  that  all  the  mothers  of  this  series 
left  the  hospital  in  good  condition. 

Duration  of  the  Disease. — The  disease  is  usually  of  short  duration  and 
the  child  which  is  to  recover  usually  turns  the  corner  within  forty-eight 
hours.  A  baby  may  ha\'e  only  one  small  hemorrhage,  and  then  being  able 
to  assimilate  its  food,  its  resistance  and  coagulating  power  of  its  blood 
improves  and  no  further  bleeding  occurs.  On  the  other  hand  the  hemor- 
rhage may  continue  and  increase  in  spite  of  treatment  and  the  baby  die. 
The  general  condition  of  the  baby  usually  shows  considerable  prostra- 
tion and  there  is  a  loss  of  weight.  The  temperature  usually  rises  as  the 
weight  falls. 

Fetal  Mortality. — This  varies  markedly  with  the  treatment  and  its 
promptness  of  administration.  In  this  series  of  18  cases  all  but  1  were 
treated  with  human  blood  serum.  This  1  was  a  mild  case  and  recovered 
without  it.  Among  the  17  treated  with  the  serum  there  were  6  deaths, 
the  mother  of  1  of  the  cases  being  distinctly  syphilitic. 

Treatment. — In  the  past  various  therapeutic  remedies  have  been  used 
for  this  condition  among  which  adrenalin,  the  lactate  of  calcium  and 
solutions  of  gelatin  have  been  the  most  popular.  The  results  from  this 
medical  treatment  were  far  from  satisfactory.  In  18  recorded  cases  at 
the  Lying-in  Hospital,  New  York,  as  reported  by  Welch,  there  were  17 
deaths.  In  1910  Welch^  reported  his  use  of  human  blood  serum  in 
cases  of  hemorrhage  of  the  newborn,  having  used  it  in  12  cases  and 

1  Normal  Human  Blood  Serum  as  a  Curative  Agent  in  Hemophilia  Neonatorum,  The 
American  Journal  of  the  Medical  Sciences,  June,  1910. 


HEMORRHAGIC  DISEASE  OF  THE  NEWBORN  415 

succeeding  in  checking  the  bleeding  in  each  case.  At  this  time  the 
author  in  his  service  at  the  Sloane  Hospital  was  using  rabbit  serum  for 
the  same  purpose,  but  although  his  results  were  better  than  with  the 
drugs  previously  employed,  they  were  not  as  good  as  those  of  Welch  with 
human  serum  and  the  use  of  rabbit  serum  was  abandoned  and  human 
serum  adopted  in  its  place. 

Dosage. — The  blood  is  drawn  into  a  sterile  flask  and  allowed  to  coagu- 
late. As  soon  as  the  serum  has  separated  it  may  be  withdrawn  and 
injected.  Even  in  mild  cases  it  is  well  to  inject  subcutaneously  about 
30  c.c.  (10  to  15  c.c.  at  a  time)  during  the  first  twenty-four  hours.  If  the 
case  is  a  severe  one  this  amount  may  be  increased  and  given  at  shorter 
intervals  with  safety  and  advantage.  It  is  usually  injected  under  the 
skin  of  the  back  and  is  rapidly  absorbed.  The  treatment  should  be  con- 
tinued until  the  bleeding  ceases.  Of  late  it  has  been  found  that  if  the 
case  is  an  urgent  one  it  is  not  necessary  to  wait  for  the  serum  to  separate, 
but  some  of  the  Avhole  blood  may  be  taken  from  the  mother's  vein  and 
injected  immediately  beneath  the  skin  of  the  baby's  back.  The  author 
has  several  times  recently  made  use  of  this  method  with  advantage. 


PART  in. 
PATHOLOGICAL  PREGNANCY. 


CHAPTER  XII. 
TOXEMIA  OF  PREGNANCY. 

While  in  the  majority  of  cases  pregnancy  pursues  a  normal  physio- 
logical course,  disturbances  of  metabolism  and  faulty  elimination  with 
associated  pathological  lesions  are  very  frequent  and  present  various 
symptomatic  pictures  referred  now  to  the  stomach,  now  to  the  nervous 
system  and  again  to  the  liver,  the  kidney,  the  skin  or  the  vascular  sys- 
tem. These  varied  symptom  groups  are  collected  by  the  practical  obstet- 
rician under  the  general  term  of  toxemia  of  pregnancy  and  the  puerperium, 
which  includes  not  only  the  pernicious  vomiting  of  pregnancy  but  the 
headache^  high-tension  pulse,  albuminuria,  disturbances  of  vision,  certain 
skin  eruptions,  the  nervous  symptoms  indicating  a  threatened  eclampsia, 
and  even  the  eclamptic  seizure  itself. 

The  exact  etiology  of  this  toxemia  is  still  unknown,  but  whatever  it 
may  prove  eventually  to  be,  it  is  generally  agreed  that  the  symptoms 
and  pathological  changes  of  the  toxemia  of  pregnancy  and  the  puerperium 
are  caused  by  some  toxin  or  toxins  circulating  through  the  system  and 
that  with  this  there  is  associated  some  fault  in  the  elimination  of  the 
products  of  metabolism. 

PERNICIOUS  VOMITING  OF  PREGNANCY  OR  HYPEREMESIS 
GRAVIDARUM. 

About  one-half  of  all  pregnant  women  suffer  with  more  or  less  nausea, 
and  occasional  vomiting  during  the  early  months  of  their  pregnancy 
especially  in  the  morning.  This  usually  begins  in  the  early  part  of  the 
second  month  and  ceases  spontaneously  in  the  latter  part  of  the  third  or 
early  part  of  the  fourth  month.  While  some  of  this  vomiting  in  the 
early  months  may  be  toxemic  in  origin,  and  that  occurring  in  the  latter 
months  of  pregnancy  almost  always  is,  there  is  a  form  of  vomiting  occur- 
ring in  the  early  months  of  pregnancy,  often  spoken  of  as  "morning 
sickness,"  which  may  be  looked  upon  as  reflex  or  neurotic  and  almost 
a  physiological  accompaniment  of  pregnancy.  This  nausea  and  vomiting, 
although  most  often  occurring  in  the  morning,  may  vary  greatly  in 
different  people,  both  in  its  time  of  occurrence  and  in  its  duration.  In 
27  (417) 


418  TOXEMIA   OF  PREGNANCY 

some  women  it  appears  only  at  night  and  in  others  it  may  last  throughout 
the  whole  pregnancy  instead  of  being  confined  to  the  early  months.  The 
reflex  or  neurotic  character  of  the  vomiting  can  sometimes  be  demon- 
strated by  causing  it  to  disappear  by  correcting  a  malposition  of  the 
uterus,  by  prescribing  a  simple  placebo,  or  by  some  other  form  of  mental 
suggestion.  This  form  of  vomiting  is  looked  upon  as  extremely  annoying, 
and  perhaps  interfering  with  the  mother's  nutrition,  but  not  ks  a  serious 
condition. 

On  the  other  hand,  thanks  to  the  labors  of  Ewing,  Stone,  Williams,  and 
others,  there  is  now  recognized  a  distinct  pathological  vomiting  called 
"l)ernicious  vomiting  of  pregnancy"  or  "hyperemesis  gravidarum"  with 
definite  ])athological  lesions. 

This  vomiting  is  toxemic  in  origin  and  the  condition  of  the  patient 
may  become  extremely  critical  and  may  even  terminate  fatally.  The 
trouble  may  begin  as  an  ordinary  morning  sickness,  but  the  complete 
picture  of  the  pernicious  vomiting  of  pregnancy  includes  an  emaciated 
patient  with  flushed  face,  dry  lips  and  tongue,  with  a  sweetish  odor  to 
the  breath,  a  feeble  pulse  usually  increased  in  frequency,  temperature 
usually  a  little  subnormal  until  near  the  end,  when  as  the  toxemia  increases 
the  temperature  usually  rises.  There  is  inability  to  retain  anything  on 
the  stomach,  frequent  retching,  perhaps  vomiting  of  blood  or  coffee- 
ground  material,  and  the  patient  is  often  jaundiced. 

To  this  clinical  picture  there  are  added  definite  changes  in  the  urine 
and  distinct  lesions  in  the  liver  and  kidneys. 

Changes  in  the  Urine.— In  this  toxemic  vomiting  the  urine  is  diminished 
111  amount.  It  may  contain  but  little  albumin,  perhaps  a  few  casts.  It 
often  shows  acetone,  diacetic  acid,  /3-oxybutyric  acid  and  indican.  It 
ma\'  contain  blood,  perhaps  leucin  and  ty rosin.  As  pointed  out  by 
Williams,  in  1906,  the  nitrogen  ratios  in  the  urine  of  toxemic  vomiting 
differ  markedly  from  the  normal,  showing  a  disturbance  of  proteid  metab- 
olism with  faulty  oxidation.  The  percentage  of  ammonia  nitrogen  is 
increased,  while  that  of  urea  nitrogen  is  diminished. 

In  order  to  interpret  the  abnormal  it  is  necessary  to  understand  the 
normal  nitrogen  output,  and  for  this  reason  the  author  placed  in  bed 
for  nine  days  at  the  Sloane  Hospital  for  Women  two  normal  pregnant 
women  in  their  last  month  of  pregnancy.  Their  diet  was  solely  milk 
and  water,  the  same  diet  which  our  toxemic  patients  would  be  likely 
to  receive  and  the  nitrogen  ratios  in  the  twenty-four-hour  specimens 
of  the  women  were  determined  by  a  professional  chemist  for  each  of  the 
nine  days  with  the  following  results: 
In  one  the  average  for  the  nine  days  was: 

A.,,r„«„:„  .,;*..„ TT  •  Amido-acid  and  undetermined 

Ammonia  nitrogen.  Urea  nitrogen.  nitrogen. 

4., 37  per  cent.  *       84.63  per  cent.  5.78  per  cent. 

In  the  other: 

»„„„■■,  ^^  .  Amido-acid  and  undetermined 

Ammonia  nitrogen.  Urea  nitrogen.  nitrogen. 

5.95  per  cent.  81.9  per  cent.  7.09  per  cent. 


PERNICIOUS   VOMITING  OF  PREGNANCY  419 

This  makes  the  average  for  the  two  patients  for  the  nine  days: 

Amido-aeid  and  undetermined 
Ammonia  nitrogen.  Urea  nitrogen.  nitrogen. 

5.16  per  cent.  83.26  per  cent.  6.43  per  cent. 

These  figures  may  be  regarded  as  fairly  accurately  representing  the 
normal  nitrogen  ratios  of  normal  pregnant  women  on  milk-and-water 
diet  in  the  last  month  of  pregnancy. 

In  the  experience  of  the  author  the  cases  of  pernicious  vomiting  have 
shown,  as  a  rule,  a  high  ammonia  nitrogen  and  a  low  urea  nitrogen  and 
as  the  patient  has  become  worse  the  percentage  of  ammonia  nitrogen 
has  increased  and  that  of  urea  nitrogen  decreased.  Furthermore,  as  the 
patient  has  improved  the  opposite  condition  has  prevailed,  viz.,  the 
ammonia  nitrogen  has  decreased,  while  the  urea  nitrogen  has  increased. 
This  is  shown  by  the  urinary  findings  in  the  following  case  occurring  at 
the  Sloane  Hospital  for  Women:  Mrs.  A.,  aged  nineteen  years,  admitted 
to  the  hospital  February  8,  1912.  In  June,  1910,  and  again  in  January, 
1911,  she  had  been  obliged  to  have  a  pregnancy  interrupted  at  about  the 
third  month  on  account  of  hyperemesis.  Her  last  menstruation  before 
admission  to  the  hospital  occurred  on  December  20,  1911.  Since  the 
middle  of  January  she  had  been  suffering  with  nausea  and  vomiting  and 
for  the  week  preceding  admission  she  had  not  been  able  to  retain  anything 
on  her  stomach.  In  spite  of  colon  irrigations,  rectal  feeding,  etc.,  her 
condition  steadily  grew  worse,  and  on  February  13  her  urea  nitrogen  was 
40.7  per  cent,  of  total  nitrogen,  and  her  ammonia  nitrogen  was  23.8 
per  cent,  of  total  nitrogen. 

Her  uterus  was  emptied  on  February  14  and  she  began  at  once  to 
improve.  Her  stomach  on  the  following  day  was  able  to  retain  food  and 
on  February  17  her  urea  nitrogen  was  45.7  per  cent,  and  her  ammonia 
nitrogen  was  11.4  per  cent.  On  February  28  her  urea  nitrogen  was  68.4 
per  cent,  and  her  ammonia  nitrogen  was  4.37  per  cent.,  and  she  was 
discharged  cured. 

The  degree  in  which  these  urinary  changes  are  present  in  a  given  case 
of  pernicious  vomiting  and  the  fact  of  their  increasing  or  decreasing  under 
treatment  will  often  prove,  when  studied  in  connection  with  the  clinical 
picture,  of  great  value  in  determining  the  gravity  of  the  situation  and 
the  prognosis.  It  should  be  stated,  however,  that  occasionally  a  careful 
study  of  the  clinical  picture  of  the  patient  will  show  an  improvement 
before  the  laboratory  findings,  and  will  justify  the  obstetrician  in  refrain- 
ing from  emptying  the  uterus  even  if  the  urinary  report  does  not  show 
improvement. 

On  the  other  hand,  failure  to  recognize  the  condition  of  severe  pernicious 
vomiting  of  pregnancy  and  allowing  the  patient  to  go  unrelieved  until 
she  becomes  jaundiced,  has  hemorrhages  from  the  mucosa  of  the  alimen- 
tary canal  or  into  the  skin,  and  until  she  has  a  rapid,  feeble  pulse  and  a 
rising  temperature,  often  results  in  the  loss  of  the  patient,  the  procedure 
of  terminating  the  pregnancy  having  been  postponed  too  long.  This 
danger  can  best  be  impressed  upon  the  obstetrician  by  a  study  of  the 


420 


TOXEMIA  OF  PREGNANCY 


pathological  lesions  of  the  condition.     As  these  lesions  are  found  chiefly 
in  the  liver  a  section  of  a  normal  liver  will  be  shown  first  for  comparison 


Fig.  288.— Normal  liver.      X  100. 


Fig.  289. — Liver  of  pernicious  vomiting.     Diffuse  fatty  degeneration. 


PERNICIOUS   VOMITING  OF  PREGNANCY  421 

(see  Fig.  288).  The  chief  pathological  lesion  found  in  the  pernicious 
vomiting  of  pregnancy  is  a  fatty  and  hydropic  degeneration  of  the  Uver 
which  is  apt  to  be  diffuse,  as  is  shown  in  Figs.  289  and  290,  but  in  some 
cases  is  zonal  and  goes  on  to  necrosis.  This  zonal  necrosis  when  present 
is  more  apt  to  be  central,  or  between  the  centre  and  the  periphery  of  the 
lobule  (see  Fig.  291)  rather  than  at  the  periphery,  although  often  the 
fatty  degeneration  is  most  marked  at  the  periphery.  In  this  fatty 
degeneration  and  autolysis  of  the  liver,  although  hemorrhage  from  the 
alimentary  canal  is  not  uncommon,  there  seems  to  be  little  tendency  to 
hemorrhage  into  the  liver  itself  as  is  so  often  seen  in  eclampsia.  In  some 
cases,  especially  if  the  condition  has  existed  for  a  considerable  time,  the 
lesion  is  practically  identical  with  that  of  acute  yellow  atrophy  (see  Fig. 
292). 


Fig.  290. — Liver  of  pernicious  vomiting.      X  500.     High  power  of  Fig.  289. 


The  kidneys  in  cases  of  pernicious  vomiting  show  more  or  less  degenera- 
tion of  the  epithelium  of  the  convoluted  tubules. 

Treatment. — At  the  onset  the  condition  should  be  looked  upon  as  a 
toxemia  associated  with  faulty  protein  metabolism  and  with  a  tendency 
to  pathological  lesions  in  liver  and  kidneys,  especially  the  former.  With 
this  as  a  working  hypothesis  treatment  should  consist  in  reducing  the 
ingestion  of  protein  food;  in  favoring  elimination  especially  through 
the  bowels  and  kidneys  and  if  improvement  is  not  soon  manifest  the  uterus 
should  be  emptied  before  the  liver  changes  become  severe. 

As  regards  diet,  if  any  food  can  be  retained  by  the  stomach,  meats 
should  be  avoided  and  milk,  either  plain,  diluted  milk  or  some  of  the 


422 


TOXEMIA  OF  PREGNANCY 


Fic.  291. — Pernicious  vomiting  of  pregnancy.     Necrosis  between  centre  and  periphery  of 

liver  lobule. 


Fig.  292. — Liver  of  pernicious  vomiting.     Acute  yellow  atrophy. 


PERNICIOUS   VOMITING  OF  PREGNANCY  .         423 

milk  preparations  as  matzoon,  koumiss,  etc.,  and  cereals  may  be 
administered.  If  the  stomach  rejects  all  food,  attempts  at  mouth  feed- 
ing should  be  abandoned  and  the  patient's  nutrition  maintained,  if  pos- 
sible, by  nutrient  enemata,  as  for  instance,  of  peptonized  milk. 

The  use  of  sodium  bicarbonate  in  the  treatment  of  the  toxemia  of  preg- 
nancy depends  upon  its  antiketogenic  property,  that  is,  upon  its  ability 
to  inhibit  the  production  or  at  least  to  neutralize  the  effects  of  acetone 
bodies  consisting  of  acetone,  diacetic  acid  and  |3-oxybutyric  acid.  For 
whatever  be  the  primary  cause  of  the  toxemia  of  pregnancy,  recent 
investigations  of  the  urine  have  shown  that  clinically  these  states  are 
frequently  accompanied  by  acidosis,  or  the  overproduction  of  the 
above-named  acid  bodies.  The  organism  defends  itself  against  the 
necessarily  deleterious  effect  of  these  bodies  by  neutralizing  them  first 
with  the  fixed  alkalies  of  the  body  (sodium,  potassium,  etc.),  and  later 
by  increased  formation  and  excretion  of  ammonia.  This  explains  why 
the  urinary  ammonia  serves  as  a  fair  index  of  the  degree  of  acidosis 
present.  Neither  of  the  methods  of  self-defense,  however,  can  be  con- 
tinued indefinitely  or  be  looked  upon  as  harmless  to  the  body.  The  with- 
drawal of  the  fixed  alkalies  interferes  with  the  functions  of  the  protoplasm 
of  the  cells  by  diminishing  their  normal  alkaline  or  neutral  reaction, 
while  the  excretion  of  ammonia  interferes  with  the  urea  metabolism.  The 
addition  of  sodium  bicarbonate  gives  the  body  additional  alkali  both  for 
neutralization  of  the  acids  formed  and  for  their  mobilization,  that  is,  for 
their  excretion  through  the  kidneys  without  much  damage  to  these  organs ; 
it  thus  spares  both  the  fixed  alkalies  of  the  body  and  the  normal  urea 
metabolism.  As  the  acids  are  continuously  produced,  the  administra- 
tion of  the  alkali  must  be  prolonged  and  the  quantity  sufficient  for  each 
individual  case,  the  reaction  of  the  urine  and  the  amount  of  ammonia 
in  the  urine  serving  as  index  of  the  conditions.  In  cases  of  extreme 
acidosis  the  intravenous  administration  of  an  alkali,  sodium  carbonate 
or  bicarbonate,  should  be  considered  just  as  in  the  parallel  condition  of 
acidosis  and  coma  in  the  course  of  diabetes. 

Of  all  remedial  measures  the  author  knows  of  none  which  have  served 
him  as  well  as  colon  irrigations  with  soda  solution  once  or  twice  daily, 
serving  the  triple  purpose  of  removing  toxins  from  the  intestine,  and 
furnishing  fluid  and  an  alkali  to  the  system.  During  the  period  of  treat- 
ment by  colon  irrigations  and  nutrient  enemata,  however,  the  urinary 
findings,  especially  the  nitrogen  ratios  and  also  the  clinical  picture  of 
the  patient,  should  be  carefully  studied  and  if  within  a  few  days  improve- 
ment is  not  evident,  the  uterus  should  be  emptied;  a  procedure  which 
if  not  too  long  delayed  is  usually  followed  by  a  rapid  convalescence. 
It  is  seldom  safe  to  attempt  to  maintain  the  nutrition  of  a  patient  suffer- 
ing from  toxemic  vomiting  by  nutrient  enemata  alone  for  more  than  a 
week.  The  patient  needs  fluid  both  for  body  tissues  and  for  purposes 
of  elimination  and  if  any  water  can  be  retained  by  the  mouth  it  is  a  dis- 
tinct advantage  to  allow  it. 

If  emptying  of  the  uterus  becomes  necessary,  the  anesthetic  used,  for 
reasons  which  will  be  discussed  later,  should  be  ether  rather  than  chloro- 
form. 


424 


TOXEMIA  OF  PREGNANCY 


THREATENED   ECLAMPSIA    AND   ECLAMPSIA. 

Etiology. — The  generally  accepted  view  today  is  that  in  each  of  these 
two  conditions  there  is  a  toxemia,  but  that  in  eclampsia  in  addition  to 
the  toxemic  condition  there  is  added  a  convulsion. 

In  other  words  the  toxemia  is  generally  not  called  eclampsia  unless 
an  explosion  in  the  shape  of  a  convulsion  has  occurred  and  yet  this  is 
only  an  incident  in  the  condition  of  toxemia  and  a  woman  may  escape 
a  convulsion  simply  because  her  increasing  toxemia  is  recognized,  her 
diet  is  restricted,  elimination  is  favored  and  her  blood-pressure  reduced, 
or  because  labor  intervenes  and,  as  usually  happens,  the  toxemia  then 


Fig.  293. — Liver  of  eclamptic  patient.     Hepatic  type. 

rapidly  lessens.    Such  being  the  case,  threatened  eclampsia  and  eclampsia 
may  properly  be  considered  under  the  same  heading. 

Pathology. — Our  knowledge  of  the  pathology  of  eclampsia  is  of  com- 
paratively recent  date,  but  thanks  to  the  work  of  Jurgens,  Schmorl,  Wil- 
liams, Ewing,  and  others,  the  lesions  are  now  well  recognized.  The 
changes  are  mainly  those  of  congestion,  hemorrhage,  parenchymatous 
degeneration  and  necrosis.  The  liver  and  kidneys  are  the  organs  chiefly 
involved,  the  lesions  varying  with  the  clinical  type.  Thus,  in  those  cases 
characterized  by  vomiting,  jaundice,  a  tendency  to  hemorrhage,  with 
little  edema  and  slight  albuminuria,  the  liver  is  the  organ  most  involved, 
as  seen  in  Figs.  293,  294,  and  295,  which  represent  the  liver  and  kidney  of 
the  same  patient.    Here  the  liver  is  markedly  involved  and  the  kidney 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA 


425 


Fig.  294. — Liver  of  eclampsia.     Hepatic  type.     High  power  of  Fig.  293.      X  500. 
Taken  at  periphery  of  lobule. 


Fig.  295. — Kidney  of  eclamptic  patient  whose  liver  is  shown  in  Figs.  293  and  294. 


426 


TOXEMIA   OF   PREGXANCY 


but  little  involved.  The  history  of  this  case  was  briefly  as  follows:  Mrs. 
]\I.,  aged  nineteen  years,  twelve  hours  after  a  normal  labor  at  the  Sloane 
Hospital  for  Women,  suddenly  turned  in  bed,  called  out  "What's  that?" 
had  a  convulsion,  went  from  bad  to  worse;  on  the  fifth  day  vomited  blood; 
died  on  the  sixth  day.  Her  urine  showed  only  a  trace  of  albumin  at  any 
time,  with  a  few  hyaline,  epithelial  and  granular  casts.  Her  liver  showed 
marked  necrosis  at  the  centre  of  the  lobules  (see  Fig.  293),  a  zone  of  fatty 
and  hydropic  degeneration  near  the  periphery  (see  Fig.  294),  and  a  tew 
normal  liver  cells  at  the  periphery  along  the  portal  vessels. 

On  the  other  hand,  in  the  cases  characterized  by  headache,  high-ten- 
sion pulse,  marked  disturbance  of  the  nervous  system,  marked  albumin- 


FlG, 


'Mi 

296. — Liver  of  another  eclamptic  patient. 


uria  and  edema,  the  kidney  changes  are  more  marked,  as  is  seen  in  Figs. 
29(),  297,  and  298,  which  represent  the  liver  and  kidney,  respectively, 
of  the  same  patient.  Here  the  liver  changes  are  slight  while  the  kidney 
changes  are  very  pronounced.  The  history  of  this  case  was  briefly  as 
follows:  She  was  brought  to  the  Sloane  Hospital  in  coma  at  0.30  p.m., 
having  had  three  convulsions  before  admission.  Her  urine  became  solid 
on  boiling  and  showed  numerous  casts.  An  elastic  bag  was  introduced 
on  admission  and  she  was  delivered  about  midnight.  She  had  five  con- 
vulsions between  the  time  of  her  admission  and  delivery  and  two  after 
delivery.  She  died  on  the  third  day.  The  kidneys  (see  Fig.  29S)  showed 
a  chronic  diffuse  nephritis  with  the  formation  of  new  connective  tissue; 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA  427 


Fig.  297.— Liver  of  eclampsia.     Nephritic  type;  high  power  of  Fig.  296.      X  500. 
Taken  at  periphery  of  lobule. 


Fig.  298.— Kidney  of  eclamptic  patient  whose  liver  is  shown  in  Figs.  296  and  297. 


428 


TOXEMIA  OF  PREGNANCY 


the  tubules  were  dilated  and  the  epithelium  largely  degenerated;  an 
acute  exacerbation  of  a  chronic  process. 

Many  border-line  cases  present  themselves  in  which  both  the  liver 
and  the  kidneys  are  involved,  yet  in  every  large  maternity  service  these 
two  distinct  clinical  types — the  liver  type  and  the  kidney  type — are 
often  seen. 

The  lesions  in  the  liver  vary  from  congestion  with  granular  and  fatty 
degeneration  to  necrosis  with  almost  complete  dissolution  of  the  liver 
parenchyma.  This  necrosis  begins  at  the  centre  of  the  lobule  and  extends 
toward  the  periphery,  leaving  only  a  mass  of  granular  detritus  surround- 
ing the  central  \ein,  the  nuclei  and  cell  contents  disappearing  with  only 
a  reticular  network  in  the  place  of  the  liver  cells.     Thromboses  with 


Fig.  299. — Liver  of  eclampsia,  hemorrhagic  type. 


hemorrhage  occur  throughout  the  lobule  more  often  at  the  periphery 
(see  Fig.  299).  The  organ  may  be  swollen  or  diminished  in  size,  according 
to  the  change  in  the  parenchyma.  It  usually  presents  a  yellowish  color 
and  may  have  hemorrhages  under  the  capsule.  The  kidneys  are  swollen, 
the  cortex  thickened  and  pale,  the  markings  less  distinct  than  normal  and 
the  capsule  not  adherent.  Microscopically  the  cells  of  the  cortical  tubules 
are  swollen,  in  many  places  disintegrating.  The  vessels  are  injected  and 
the  tubules  contain  much  granular  material.  Other  changes  found  are 
moderate  fatty  degeneration  of  the  heart,  and  edema,  congestion  and 
hemorrhages  in  the  brain.  The  body  often  shows  edema,  subcutaneous 
hemorrhages,  and  jaundice.  The  above  are  the  pathological  changes  in 
the  severe  grades  of  toxemia  of  pregnancy  and  the  puerperium. 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA  429 

Symptoms. — Of  the  greatest  importance  to  every  student  and  practi- 
tioner of  obstetrics  today  is  the  early  recognition  of  the  symptoms  of  the 
toxemia  of  pregnancy,  as  it  is  chiefly  by  the  recognition  and  treatment  of 
these  early  symptoms  that  the  more  severe  grades  of  toxemia  and  those 
threatening  eclampsia  with  its  dire  results  can  be  avoided. 

The  condition  of  toxemia  is  a  most  insidious  one  and  its  early  signs 
and  symptoms  often  so  closely  resemble  the  harmless  mechanical  results 
of  the  pressure  of  the  large,  heavy  uterus,  with  its  contents,  that  they 
frequently  escape  the  detection  of  all  save  the  most  careful  observers. 

Edema. — It  is  true  that  in  the  latter  half  of  pregnancy  it  is  not  at  all 
unusual,  as  a  result  of  the  mechanical  pressure  above,  to  have  a  certain 
amount  of  edema  of  the  feet  and  legs.  It  is  true  that  on  account  of  the 
condition  of  the  blood  in  pregnancy  it  is  not  unusual  to  have  a  change 
in  the  expression  of  the  face  and  perhaps  a  little  swellmg  of  the  fingers 
so  that  the  rings  fit  more  tightly  than  normal.  This  is  all  true,  but  these 
may  be  the  symptoms  of  a  beginning  toxemia  and  nothing  but  a  careful 
and  frequent  examination  of  the  urine  will  determine  whether  these  signs 
and  symptoms  are  of  no  moment,  or  whether  they  indicate  grave  condi- 
tions which  must  be  treated  promptly  and  thoroughly. 

The  Urine. — In  the  toxemia  of  pregnancy,  even  in  the  severe  grades 
threatening  eclampsia,  the  m-ine  varies  greatly  in  different  patients, 
depending  largely  upon  whether  the  lesion  involves  chiefly  the  liver  or 
the  kidneys. 

The  quantit}'  of  the  urine  is  sometimes  greatly  diminished,  even  to 
eight  or  ten  ounces  in  the  twenty-four  hours,  and  the  first  evidence  of 
improvement  in  the  patient  may  be  an  increase  in  the  amount  of  urine 
pa,ssed.  iVfter  a  convulsion  the  urine  may  be  almost  suppressed  and  what 
is  passed  be  of  a  distinctly  smoky  color.  The  amount  of  urea  excreted 
may  vary  greatly  in  different  patients,  depending  largely  upon  the  diet 
taken.  Two  patients  under  the  observation  of  the  author  passed  only 
seventy-five  grains  of  urea  a  day  throughout  their  whole  pregnancy. 
These  patients  were  on  a  diet  from  which  red  meats  were  excluded,  but 
never  presented  signs  of  more  than  the  mildest  grade  of  toxemia. 

The  amount  of  albumin  in  the  urine  of  a  patient  suffering  from  toxemia 
varies  greatly.  In  about  10  per  cent,  of  the  cases  there  is  none  save  the 
merest  trace  of  albumin  in  the  urine  until  after  the  first  convulsion,  while 
in  others  it  is  found  in  variable  amounts  even  to  a  degree  in  which  the 
urine  nearly  solidifies  on  boiling.  After  a  convulsion  it  is  the  rule  for  the 
urine  to  contain  a  large  amount  of  albumin  even  if  it  showed  little  if  any 
before.  The  large  amounts  of  albumin  in  the  urine  of  toxemic  patients 
are  found  especially  in  those  in  whom  the  kidneys  are  the  organs  chiefly 
involved  and  in  those  suffering  with  a  chronic  nephritis  to  which  the 
pregnancy  has  added  an  acute  exacerbation. 

In  the  severe  grades  of  toxemia,  and  especially  in  eclampsia,  the  urine 
contains  numerous  casts,  hyaline,  granular,  and  epithelial. 

High  Blood-pressnre. — Another  evidence  of  beginning  toxemia  and 
one  the  importance  of  which  is  receiving  more  and  more  recognition  is 
a  rising  blood-pressure.    The  blood-pressure  in  pregnancy  varies  in  dif- 


430  TOXEMIA   OF  PREGNANCY 

ferent  women,  as  is  stated  on  page  155,  but  the  average  is  about  113  mm. 
In  a  beginning  toxemia  the  blood-pressure  rises  until  in  an  eclamptic 
seizure  or  in  the  posteclamptic  coma  it  may  register  well  above  200. 
The  highest  blood-pressure  met  with  by  the  author  in  a  patient  who  did 
not  have  a  convulsion  was  232,  but  this  is  an  exceptional  experience.  A 
safe  rule  is  to  look  with  suspicion  upon  any  blood-pressure  in  pregnancy 
above  140  and  to  consider  that  usually  it  is  below  125.  The  importance 
of  the  blood-pressure  as  an  indication  of  toxemia  emphasizes  the  need  of 
the  frequent  use  of  the  sphygmomanometer. 

Headache. — The  occurrence  of  frequent  headaches  in  pregnancy  should 
always  be  looked  upon  as  a  probable  indication  of  a  toxemia  and  as  one 
of  the  proofs  that  they  have  a  toxic  origin  may  be  mentioned  the  fact 
that  the  treatment  most  likely  to  give  relief  is  that  along  the  line  of 
elimination,  colon  irrigations,  etc. 

Nausea  and  ]'()mitin(j. — In  the  early  months  of  pregnancy  it  has  been 
shown  that  vomiting  is  often  of  toxemic  origin  and  in  the  type  called 
pernicious  vomiting  such  is  always  the  case.  In  the  latter  months  of 
pregnancy  even  more  uniformly  than  earlier,  vomiting  should  always 
be  looked  upon  as  toxemic  and  an  eclamptic  seizure  not  infrequently 
begins  with  a  severe  headache  and  vomiting  soon  to  be  followed  by  a 
convulsion. 

Nervous  System. — In  the  severe  grades  of  toxemia,  especially  that 
threatening  eclampsia,  the  nervous  system  usually  show^s  changes  from 
the  normal  equilibrium.  The  patient  may  be  restless,  irritable  and  suffer 
fjom  insomnia,  or  on  the  other  hand  she  may  be  dull,  apathetic,  sleepy, 
and  stupid. 

The  Eyes. — Not  infrequently  one  of  the  early  manifestations  of  tox- 
emia is  a  disturbance  of  vision,  perhaps  a  blurring  of  the  vision  or  the 
appearance  of  spots  before  the  eyes,  musc?e  volitantes.  Occasionally 
the  ophthalmologist  is  first  consulted  for  improvement  of  the  vision  and 
he  diagnoses  the  hemorrhagic  retinitis  resulting  from  the  toxemia.  The 
seriousness  of  the  result  of  the  eye  lesions  depend  upon  the  extent  and 
location  of  the  hemorrhages.  If  small  and  located  outside  the  field  of 
vision  they  may  be  entirely  recovered  from,  but  if  centrally  located  the 
vision  may  be  permanently  impaired. 

Hemorrhages  into  the  retina  should  always  be  looked  upon  as  one  of 
the  serious  symptoms  of  toxemia.  In  some  cases  presenting  ocular  symp- 
toms, no  lesion  can  be  demonstrated  and  the  symptoms  rapidly  disap- 
pear with  the  toxemia.  In  some  instances  the  patient  complains  of  ring- 
ing in  the  ears  (tinnitus  aurium)  as  one  of  the  symptoms  of  her  toxemia. 
The  symptoms  of  the  toxemia  of  pregnancy,  which  may  or  may  not  lead 
to  a  convulsion  have  now  l)een  described  and  will  be  recapitulated  as 
follows:  Edema;  increasing  urinary  changes  (albumin,  casts,  disturbed 
nitrogen  partition,  etc.);  high  blood-pressure;  headache;  vomiting; 
disturbed  nervous  system;  disturbed  vision. 

Frequency. — An  idea  of  the  frequency  of  the  occurrence  of  eclampsia 
or  toxemia  with  convulsions  may  be  gained  from  the  fact  that  in  20,000 
consecutive  deliveries  at  the  Sloane  Hospital  for  Women  there  were  251 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA  431' 

cases  of  eclampsia,  i.  e.,  it  occurred  in  1.2  per  cent,  of  cases,  or  1  in  79. 
Of  these  251  cases,  168  occurred  in  primigravidse  and  83  in  multigravidfe. 
In  154  it  occurred  before  term  and  in  97  at  term.  200  showed  premonitory 
symptoms,  51  showed  no  premonitory  symptoms;  249  showed  albumin 
in  the  urine,  while  2  showed  none.  In  200  casts  were  found  in  the  urine 
while  in  51  no  casts  were  found.  The  eclamptic  seizure  may  occur  either 
before,  during  or  after  labor.  In  the  251  cases  mentioned  above,  the 
first  convulsion  was  antepartum  in  159,  intrapartum  in  40,  and  post- 
partum in  52,  i.  e.,  eclampsia  during  pregnancy  is  the  most  common 
occurrence.  Anything  increasing  the  congestion  or  the  demand  for 
elimination  favors  toxemia  and  eclampsia.  Hence  the  greater  frequency 
of  toxemia  in  multiple  as  compared  with  single  pregnancy.  Eclampsia 
is  not  confined  to  normal  pregnancy,  but  has  even  been  reported 'as 
occurring  in  ectopic  gestation. 

Type. — Of  the  251  cases  of  eclampsia  there  were  24  showing  hemor- 
rhages, i.  e.,  9.6  per  cent,  were  of  the  hemorrhagic  type. 

As  a  rule  careful  and  frequent  observation  of  the  condition  of  the 
urine,  the  blood-pressure  and  the  general  condition  of  the  patient  will 
tell  whether  there  is  an  increasing  toxemia,  threatening  eclampsia  or  not. 
In  51  of  the  251  cases  mentioned  above,  however,  there  were  no  premoni- 
tory symptoms  save  a  mild  albuminuria,  and  in  2  even  this  was  absent. 
It  must  be  admitted  that  in  rare  instances  even  if  the  urine  is  examined 
every  week  fulminating  cases  of  eclampsia  will  arise  as  out  of  a  clear  sky. 
This,  however,  is  extremely  exceptional  under  careful  observation. 

Eclamptic  Seizure. — Either  with  or  without  premonitory  constitu- 
tional symptoms  of  a  toxemia  the  convulsion  itself  usually  presents  the 
following  picture:  The  eyes  stare,  the  lids  twitch,  the  pupils  are  first 
contracted,  later  dilated.  The  eyes  are  insensible  to  light,  the  eye-balls 
are  rolled  upward,  and  to  one  side.  The  face  becomes  cyanotic,  the  jaws 
jerk  rapidly,  the  tongue  is  bitten  if  protruded. 

Between  the  clonic  spasms  there  is  a  tonic  spasm  of  the  different  muscles 
of  the  body  in  which  the  arms  are  flexed,  the  thumbs  flexed  into  the 
palms  and  the  fingers  are  bent  over  them.  Respiration  is  arrested  by  con- 
tractions of  the  muscles  of  the  thorax  and  the  diaphragm.  There  is  a 
rigidity  of  the  entire  body  and  limbs  with  loss  of  Sensation  and  conscious- 
ness. After  a  period  of  alternating  tonic  and  clonic  spasms  lasting  from 
one  to  five  minutes  the  patient  passes  into  a  coma  in  which  respira- 
tion returns,  at  first  irregular  and  stertorous,  then  more  natural;  at  the 
same  time  sensation  and  consciousness  gradually  return.  The  convul- 
sion, including  the  period  of  coma,  often  lasts  half  an  hour  and  then  the 
patient  may  completely  recover  consciousness  or  pass  directly  from  one 
convulsive  seizure  to  another,  the  number  depending  upon  the  degree 
of  the  toxemia  and  the  promptness  of  the  treatment.  It  is  exceptional 
for  a  patient  to  have  only  one  convulsion.  In  one  of  the  author's  cases 
which  recovered  the  patient  had  31  convulsions.  As  many  as  80  convul- 
sions have  occurred  in  one  case. 

DifEerential  Diagnosis. — It  is  only  natural  that  a  convulsion  occurring 
during  pregnancy  or  the  puerperium  should  suggest  eclampsia,  and  as  a 


432  TOXEMIA  OF  PREGNANCY 

rule  this  is  justified,  yet  this  conclusion  is  not  always  warranted.  The 
convulsion  may  be  an  expression  of  epilepsy  or  hysteria  and  attention 
may  well  be  called  to  a  few  of  the  differential  features  as  shown  in  the 

following  tables: 

Eclampsia rs.— Epilepsy. 

Patient  not  subject  to  convulsions.  Patient  subject  to  con\-ulsions. 

Urine  usually  shows  albumin.  Urine  usually  free  from  albumin. 

Edema  common.  No  edema. 

Prodromic  symptoms  of  toxemia.  No  prodromic  symptoms  save  aura. 

Rising  temperature.  No  rise  of  temperature. 

EcL.VMPSiA vs. Hysteria. 

Patient  unconscious.  Patient  not  unconscious. 

Coma  present.  No  coma. 

Urine  scanty  and  albuminous.  Urine  abundant,  without  albumin. 

Muscular  contractions  more  marked.  Muscular  contractions  less  marked. 

Treatment. — Prophylaxis. — ^Following  in  the  line  of  preventive  medicine, 
the  keynote  of  our  profession  today,  the  most  important  treatment  of 
toxemia  is  prophylaxis  and  comprises  such  observation  and  care  of  the 
pregnant  patient  as  will  lessen  the  chances  of  toxemia  on  the  one  hand, 
and  will  lead  to  the  early  detection  and  prompt  treatment  of  the  con- 
dition if  it  develops.  As  has  already  been  indicated  under  the  ^Nlanage- 
ment  of  Normal  Pregnancy  (see  page  150)  overburdening  the  system  with 
protein  metabolism  is  avoided  by  regulation  of  the  diet  and  elimination 
is  favored  by  regulation  of  the  bowels  and  large  draughts  of  water. 

In  order  to  detect  the  early  evidences  of  a  toxemia  in  pregnancy  the 
urine  must  be  examined  regularly,  at  least  as  often  as  every  two  weeks, 
even  if  the  patient  is  feeling  perfectly  well,  and  the  examination  should 
not  simply  be  for  albumin  and  casts  but  should  include  as  well  the  tests 
for  faults  in  metabolism,  especially  protein  metabolism.  If  evidences 
of  a  toxemia  are  found  the  examinations  of  the  urine  should  be  made 
more  frequently,  even  as  often  as  every  few  days. 

It  is  not  sufficient  that  the  patient  should  send  specimens  of  her  urine 
to  the  obstetrician  every  two  weeks.  She  should  be  seen  by  him  person- 
ally. Her  blood-pressure  should  be  taken  regularly.  He  should  examine 
for  edema  and  should  question  her  as  to  headaches,  vision,  digestion,  etc. 

In  this  way  only  can  the  obstetrician  inform  himself  of  the  inception 
of  toxemia  and  escape  responsibility  in  the  occurrence  of  eclampsia. 

The  Treatment  of  Toxemia  Threatening  Eclampsia. — If  the  condition  of 
toxemia  has  once  developed  the  obstetrician  may  well  be  guided  in  its 
treatment  by  the  following  five  principles : 

1.  The  products  of  metabolism  requiring  elimination  should  be  reduced. 

2.  Elimination  of  metabolic  products  should  be  favored. 

3.  High  blood-pressure  should  be  reduced. 

4.  If  the  toxemia  of  the  patient,  as  shown  by  the  urine,  blood-pressure 
and  general  condition  does  not  markedly  improve  under  the  preceding 
principles  of  treatment,  or  if  an  eclamptic  seizure  occurs,  the  uterus 
should  be  emptied. 

5.  In  all  methods  of  treatment  that  should  be  avoided  which  will 
either  reduce  the  resistance  of  the  patient  or  seriously  damage  any  of  her 
organs. 


THREATENED  ECLAMPSIA  AND  ECLAMPSIA  433 

Let  us  now  consider  these  principles  more  in  detail. 

1.  In  reducing  the  products  of  metabolism  requiring  elimination  the 
obstetrician  is  brought  face  to  face  with  the  problem  of  diet  for  the 
toxemic  patient.  As  protein  metabolism  is  that  most  often  at  fault,  it 
is  generally  agreed  that  red  meats  should  be  avoided  in  all  forms  of 
toxemia  of  pregnane}^  and  the  puerperium.  Although  in  mild  degrees 
of  toxemia  chicken  and  fish  may  be  allowed,  in  severe  forms  of  the 
condition  an  exclusive  milk  diet  with  large  draughts  of  water  is  the  diet 
of  choice,  to  which  are  added  chicken-broth,  cereals,  fruits  and  green 
vegetables,  as  the  toxemia  diminishes.  As  a  prophylactic  measure  it  is 
our  custom,  during  the  last  month  of  a  normal  pregnancy,  to  allow  the 
ingestion  of  red  meat  only  two  or  three  times  a  week. 


Fig.  300. — Apparatus  for,  and  method  of,  giving  colon  irrigations. 

2.  In  favoring  the  elimination  of  products  of  metabolism  the  three 
avenues,  the  skin,  the  urinary  tract  and  the  intestinal  tract  should 
receive  careful  attention.  Thus  elimination  through  the  skin  by  sweat- 
ing, induced  either  by  the  hot-air  bath  or  the  hot,  wet  pack,  is  a  most 
useful  measure  in  the  treatment  of  toxemia.  Elimination  through  the 
urinary  tract,  favored  by  the  ingestion  of  large  amounts  of  water,  and 
elimination  through  the  intestinal  tract,  favored  by  calomel  and  saline  or 
other  laxatives,  and  especially  by  colon  irrigations  with  saline  or  soda  solu- 
tion, are  methods  which  are  considered  routine  procedures  in  the  treat- 
ment of  this  condition.  At  the  Sloane  Hospital  colon  irrigations  are 
given  with  two  tubes  (see  Fig.  300),  and  nine  gallons  of  fluid  are  used, 
28 


434  TOXEMIA  OF  PREGNANCY 

3.  In  the  reduction  of  blood-pressure,  while  venesection  is  tiie  choice 
of  many  obstetricians,  and  was  formerly  quite  extensively  employed 
by  the  author,  its  use  has  now  been  largely  superseded  at  the  Sloane 
Hospital  by  veratrum  viride,  nitroglycerin  and  chloral,  and  with  better 
results. 

Our  method  of  using  these  drugs  in  toxemia  threatening  eclampsia  is 
as  follows :  Chloral  (30  grains)  is  administered  per  rectum  as  an  initial 
dose,  and  then  repeated  in  doses  of  from  20  to  30  grains  every  four 
to  six  hours,  according  to  the  restlessness  of  the  patient.  Nitro- 
glycerin, gr.  -V  to  Y^-Q,  every  two  to  four  hours  is  given  hypodermi- 
cally.  If,  under  the  use  of  the  larger  doses  of  these  drugs,  the  tension 
still  remains  high,  we  depend  on  the  use  of  veratrum  viride  rather  than 
venesection. 

The  preparation  used  has  been  Squibb's  fluidextract  of  veratrum  and 
the  dose  employed  has  scarcely  ever  exceeded  5  minims.  Our  rule  is  to 
give  5  minims  hypodermically  and  watch  the  effect.  As  the  frequency 
is  usually  reduced  with  the  tension,  it  is  our  custom  to  be  largely  guided 
in  repetition  of  the  dose  and  in  the  size  of  the  dose  by  the  frequency  of 
the  pulse,  although  the  reduction  in  the  tension  is  the  object  desired. 

If  at  the  expiration  of  from  one  to  two  hours  the  pulse  has  not  been 
reduced  in  frequency  to  100  or  below,  and  the  tension  correspondingly 
reduced,  a  second  hypodermic  injection  of  veratrum,  1  to  3  minims  is 
given.  The  tension  of  the  pulse  is  then  controlled,  if  not  kept  low  by  the 
continued  use  of  the  nitroglycerin,  by  repeated  doses  of  veratrum,  1  to  3 
minims,  every  four  hours. 

4.  To  repeat  the  fourth  principle  stated  earlier  in  the  book,  if  the 
toxemia  of  the  patient,  as  shown  by  the  urine,  blood-pressure,  and  general 
condition,  does  not  markedly  improve  under  the  preceding  principles  of 
treatment,  or  if  an  eclamptic  seizure  occurs,  the  uterus  should  be  emptied. 
At  the  Sloane  Hospital  some  years  ago  a  series  of  patients  was  treated^ 
on  the  palliative  plan,  favoring  elimination  without  emptying  the  uterus, 
but  the  mortality  was  so  much  greater  than  when  the  fetus  and  its  toxins 
were  eliminated  from  the  uterus  and  the  system,  that  for  the  past  ten 
years  the  rule  has  been,  given  an  eclamptic  seizure  or  a  toxemia  so  severe 
as  to  strongly  threaten  eclampsia  in  spite  of  treatment,  proceed  to  empty 
the  uterus. 

In  carrying  out  this  rule  the  fifth  principle  of  treatment  deserves  marked 
emphasis  and  will  be  restated  here,  hi  all  methods  of  treatment  that 
should  be  avoided  which  tvill  either  reduce  the  resistance  of  the  patient  or 
seriously  damage  any  of  her  organs. 

This  principle  has  an  important  bearing  on  the  method  of  emptying  the 
uterus.  Having  decided  that  the  fetus  should  be  removed  from  the 
uterus,  the  next  questions  are:  How?  and  When?  If  the  cervix  is  soft 
and  dilatable  and  the  patient  has  had  one  or  more  convulsions,  our  ow  n 
preference  is  manual  dilatation  and  delivery,  usually  by  version. 

If,  on  the  other  hand,  the  cervix  is  long  and  rigid,  we  believe  that  the 
patient  is  better  off,  even  if  delivered  several  hours  later,  to  have  her 
cervix  softened  and  dilated  by  the  preliminary  use  of  the  elastic  bag  or 


THREATENED  ECLAMPSIA  AND  ECLAMPSIA  435 

bags,  rather  than  to  be  delivered  by  an  immediate  accouchement  force, 
which  leaves  her  in  marked  shock  and  with  cervix  deeply  lacerated,  per- 
haps to  the  vaginal  junction.  Our  observation  leads  us  to  believe  that 
pronomiced  shock  and  deep  lacerations  lessen  both  the  resistance  of  the 
patient  and  her  chances  of  recovery.  In  the  cases  of  long,  rigid  cervix, 
which  do  not  readily  dilate  under  the  use  of  the  elastic  bag,  the  so-called 
vaginal  Cesarean  section  has  a  distinct  and  valuable  field  of  usefulness. 
In  a  restricted  class  of  cases  future  experience  may  prove  the  abdominal 
Cesarean  section  to  be  the  operation  of  choice. 

Now  the  question  arises  as  to  the  use  of  an  anesthetic  in  toxemia  and 
diu-ing  the  eclamptic  seizure.  For  many  years  it  was  our  custom  at  the 
Sloane  Hospital  to  administer  chloroform  to  every  patient  suffering  with 
eclampsia  and  to  give  it  to  the  patient  each  time  she  had  a  convulsion. 
This  was  done  with  the  idea  that  the  conM.ilsions  were  in  themselves 
an  element  of  grave  danger  to  the  patient  and  that  they  were  controlled 
by  the  chloroform.  Fm-thermore,  if  the  uterus  had  to  be  emptied  for 
the  toxemia  of  pregnancy,  showm  in  the  early  months  by  pernicious 
vomiting,  or  in  the  later  months  by  eclampsia,  chloroform  was  the 
anesthetic  usually  employed.  Riper  experience  has  led  us  in  the  first 
place  to  question  whether  chloroform  has  very  much  eftect  in  controlling 
the  convulsions,  and  secondly,  whether  in  the  light  of  our  present  knowl- 
edge concerning  the  effect  of  chloroform,  its  use  in  toxemia  and  eclampsia 
conforms  to  our  fifth  principle  of  treatment  recommended  above,  viz.: 
Harmful  remedies  should  be  avoided.  Recent  studies  of  the  pathological 
changes  produced  by  delayed  chloroform  poisoning  in  man  and  cliloro- 
form  anesthesia  in  dogs  have  shown  a  marked  similarity  to  those  of 
eclampsia.  These  studies  were  exhaustive  and  include  the  work  of 
Lengemann,  Osterhag,  Stiles  and  ^McDonald,  Stassman  and  others, 
together  with  the  more  recent  work  of  Howland  and  "Whipple.  The 
similarity  of  the  lesions  in  the  liver  is  shown  in  Figs.  301,  302,  and  303, 
which  represent  delayed  chloroform  poisoning  in  man,  cliloroform  anes- 
thesia of  a  dog,  and  eclampsia.  The  most  striking  result  of  these  studies 
was  the  extent  of  the  degeneration  and  necrosis  found  in  the  li\'er  and 
kidney  after  chloroform  anesthesia  of  short  duration. 

It  has  been  found  in  experiments  on  dogs  that  characteristic  lesions 
are  regularly  produced,  varying  in  degree  with  the  duration  and  depth 
of  anesthesia  and  also  with  idiosyncrasy.  Thus  after  thirty  minutes  to 
one  hour  anesthesia  with  chloroform  the  centres  of  the  lobules  of  the 
liver  show  congestion  with  granular  and  fatty  degeneration,  the  inner- 
most cells  being  necrotic,  their  nuclei  not  taking  the  stain  and  the  proto- 
plasm being  deeply  stained  pink  T\-ith  eosm.  With  more  prolonged 
action  the  changes  approach  those  fomid  in  delayed  chloroform  poison- 
ing m  man.  The  liver  appears  yellow  and  fatty  with  scattered  hemor- 
rhages. The  cells  about  the  centres  of  the  lobules  are  entirely  necrotic, 
a  granular  mass  remaining.  Outside  of  this  is  an  area  of  cells  which 
have  undergone  hyaline  and  fatty  degeneration,  vdih  normal  cells  at  the 
periphery.  In  some  cases  the  liver  cells  have  almost  entirely  disappeared 
with  onh-  a  few  scattered  living  cells  in  the  portal  spaces.    In  the  kidney 


43G 


TOXEMIA   OF  PREGNANCY 


Fig.  301. — Delayed  chloroform  poisoiiiug  in  man. 


Fig.  302. — Liver  of  dog.     One  hour  chloroform  anesthesia. 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA 


437 


Fig.  ,303. — Liver  of  eclamptic  patient.     Hepatic  type. 


Fig.   304. — Kidney  of  dog.     Delayed  poi.soning  after  seven  and  one-half  hours  chloroform 

anesthesia. 


438  TOXEMIA  OF  PREGNANCY 

clili)rot'orin  ant'sthosia  causes  a  marked  congestion  with  a  cloudy  swelliui;' 
and  occasionally  heniorrhao-es  into  the  parenchyma  (see  Fig.  3()0- 

The  cells  of  the  tubules  are  swollen  and  granular,  occluding  most  of 
the  lumen;  in  other  phices  they  have  disa])i)eared  entirely.  Fatty 
degeneration  is  present  and  in  many  cases  pronounced.  The  heart  muscle 
may  be  pale  and  show  fat  droplets  in  its  fibers.  Hemorrhages  occur 
throughout  the  body,  particularly  in  the  serous  membranes  and  in  the 
intestinal  and  stomach  mucosa. 

Rowland  and  others  were  able,  almost  at  will,  by  continuing  the 
anesthesia,  to  produce  delayed  chloroform  poisoning  in  dogs,  with  symp- 
toms and  lesions  corresponding  in  detail  with  those  of  delayed  chloroform 
poisoning  in  man.  Thus  we  find  in  these  three  conditions,  eclampsia, 
delayed  chloroform  poisoning  in  man,  and  chloroform  anesthesia  in 
animals,  many  similarities.  Pathologically  there  is  central  necrosis, 
parenchymatous  and  fatty  degeneration  in  the  liver;  congestion,  paren- 
chymatous and  fatty  degeneration  in  the  tubules  of  the  kidney  and  a 
tendency  to  hemorrhages  throughout  the  body.  Clinically,  in  delayed 
chloroform  poisoning,  and  in  eclampsia,  there  are  vomiting,  jaundice, 
delirium,  convulsions,  and  coma.  With  these  facts  before  us,  showing 
that  chloroform  acts  as  a  poison  to  the  liver  and  kidney,  it  certainly 
seems  that  its  use  in  the  toxemia  of  pregnancy  and  eclampsia  would 
still  further  impair  these  organs  already  damaged. 

In  turning  to  ether  as  a  substitute  when  anesthesia  is  required  in 
toxemia  and  eclampsia,  the  question  naturally  arises:  Does  ether  pro- 
duce lesions  in  the  liver  and  kidney  similar  to  chloroform?  Some  work 
had  already  been  done  along  this  line,  notably  by  Bandler,  Lengeman  and 
Leflfman,  and  it  was  partly  to  confirm  scattered  observations  on  this 
subject  that  a  further  study  of  ether  anesthesia  was  undertaken  by  Dr. 
Edward  T.  Hull,^  then  Pathologist  to  the  Sloane  Hospital,  and  the  author. 

In  our  experiments  six  mongrel  dogs  of  medium  size  w^ere  given  ether 
by  inhalation  from  an  open  cone.  They  were  killed  with  ether  forty- 
eight  hours  after  the  last  anesthesia  and  autopsied  at  once.  Tissues 
were  fixed  with  Midler's  fluid  and  10  per  cent,  liquor  formaldehyd, 
equal  parts,  and  stained  with  hematoxylin  and  eosin.  Fat  was  stained 
with  Altman's  fluid,  Scharlac  R.  as  control.  Sufficient  ether  was  given 
to  produce  complete  muscular  relaxation  with  loss  of  corneal  reflex. 

Dog  1.     Given  ether  for  three  successive  hours. 

Dogs  2  and  3.     Given  ether  two  hours  each  on  two  successive  days. 

Dog  4.     Given  ether  for  two  and  a  half  hours  on  two  successive  days. 

Dog  5.     Given  ether  for  three  hours  on  two  successive  days. 

Dog  6.     Given  ether  for  two  and  a  half  hours  on  three  successive  days. 

With  dogs  3,  4,  and  6  a  section  of  liver  and  kidney  was  taken  at  the 
beginning  of  the  first  anesthesia  for  control.  The  dogs  all  took  the  anes- 
thesia well  and  appeared  bright  and  active  throughout  the  experiments 
with  the  exception  of  dog  3.     This  dog  required  artificial  respiration 

1  Cragin  and  Hull,  The  Treatment  of  Eclampsia  Including  a  Comparison  of  the  Dangers 
of  Chloroform  and  Ether  in  this  Condition,  Jour.  Amer.  Med.  Assoc,  January  7,  1911, 
Ivi,  5-11. 


THREATENED  ECLAMPSIA  AND  ECLAMPSIA 


439 


twice,  had  a  slight  cough  on  the  first  day,  which  became  more  marked 
on  the  following  days.    It  showed  no  pneumonia  on  autopsy. 

In  none  of  these  animals  could  any  necrosis  in  any  of  the  parenchyma 
be  found.  In  the  lungs  occasional  small  areas  of  a  deeper  red  than  the 
surrounding  substance,  containing  an  increase  in  amount  of  blood  on 
section,  showed  congestion.  The  heart  muscle  in  each  dog  was  found 
to  be  of  normal  color,  striations  distinct,  no  apparent  increase  in  fat. 

There  were  no  hemorrhages  in  the  mucosa  of  the  stomach  and  intes- 
tmes. 

The  livers  were  of  a  good  color  throughout,  the  vessels  in  a  few  places 
standmg  out  a  brighter  red  than  the  surrounding  structure.    The  yellow 


Fig.  305. — Liver  of  doj 


Four  and  one-half  hours  ether  anesthesia. 


appearance  was  entirely  lacking,  and  the  cells  throughout  preserved  their 
outlines  with  contents  intact  (see  Fig.  305).  There  was  no  suggestion 
of  necrosis  at  any  point.  The  protoplasm  was  somewhat  granular  and 
small  droplets  of  fat  were  found  in  the  cells  about  the  central  veins  and 
in  the  portal  spaces.  This  fat  was  only  slightly  in  excess  of  that  in  the 
controls. 

The  kidneys  were  of  normal  size,  capsule  not  adherent,  cortex  not 
thickened,  markings  distinct.  ^Microscopically  the  cells  of  the  tubules 
were  well  preserved  throughout,  their  outlines  were  distinct,  the  nuclei 
staining  sharply,  the  protoplasm  granular,  the  tubules  containing  in 
some  places  some  granular  material.  Fat  globules  were  present  in  a  few 
of  the  straight  tubules  and  in  the  lining  cells.    This  condition  seemed  no 


440 


TOXEMIA   OF  PREGNANCY 


more  than  is  normally  found  and  no  more  marked  than  in  the  controls 
taken.    The  condition  is  well  shown  in  Fig.  30(). 

No  pathological  changes  could  be  found  in  any  of  the  sections  of  pan- 
creas and  spleen.  These  facts  seem  to  demonstrate  that  in  animals,  at  least, 
ether  produces  practically  little  effect  on  the  liver  and  kidneys  as  com- 
pared with  the  very  marked  changes  in  these  organs  produced  by  chloro- 
form, and  while  it  may  be  argued  that  this  comparison  has  been  demon- 
strated only  in  animals,  the  similarity  between  the  lesions  of  delayed 
chloroform  poisoning  in  man  and  chloroform  anesthesia  in  animals  makes 
it  appear  more  than  probable  that  reasoning  as  to  the  effect  of  ether  on 
the  liver  and  kidney  of  man,  from  the  lesions  produced  by  ether  in 
animals,  is  entirely  justified. 


Fig.  306. — Kidnej-  of  dog.     Five  hours  ether  anesthesia. 

Impressed  with  the  above  facts  the  author,  in  his  service  at  the  Sloane 
hospital,  has  abandoned  entirely  the  use  of  chloroform  in  all  cases  of 
toxemia  of  pregnancy  or  eclampsia,  either  for  operative  procedure  or 
for  the  control  of  convulsions,  and  has  employed  ether  in  these  conditions, 
whenever  an  anesthetic  was  required. 

During  this  period  since  the  abandonment  of  chloroform,  aside  from 
numerous  cases  of  toxemia,  there  have  been  seventy-one  cases  of  true 
eclampsia,  i.  e.,  toxemia  with  con^•ulsions  varying  in  number  from  one 
to  thirty-one.  In  the  treatment  of  these  patients  no  attempt  has  been 
made  to  control  the  convulsions  by  means  of  the  anesthetic.  This  end 
has  been  sought  through  lowering  the  blood-pressure  and  quieting  the 
nervous  system  by  the  use  of    veratrum,   chloral,   and  nitroglycerin. 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA  441 

Ether  has  been  used  whenever  an  anesthetic  has  been  required  durmg 
delivery.  Former  experiences  with  attempts  to  control  the  convulsions 
by  chloroform  proved  that  it  was  practically  impossible.  Recent  experi- 
ences without  attempts  to  control  convulsions  by  an  anesthetic  have 
given'results  which  compare  favorably  with  those  of  the  former  method. 

In  these  71  cases  of  eclampsia  (occurring  in  8000  deliveries)  treated 
without  chloroform  there  have  been  8  deaths,  a  mortality  of  11.2  per  cent. 
In  the  251  cases  of  eclampsia  in  the  20,000  deliveries  prior  to  the  aban- 
donment of  chloroform  in  toxemia  and  eclampsia  there  were  71  deaths, 
a  mortality  of  28  per  cent.  Not  only  has  the  treatment  of  eclampsia 
without  chloroform  given  a  lower  mortality,  but  it  has  also  seemed  that 
others  having  toxemia  were  perhaps  spared  eclamptic  seizures  by  the 
avoidance  of  the  use  of  chloroform  and  the  further  damaging  of  the 
already  damaged  liver.  This  would  seem  to  be  shown  by  the  fact  that 
while  in  the  20,000  deliveries  in  which  chloroform  was  used  in  all  cases 
there  ^^-ere  251  cases  of  eclampsia;  in  the  SOOO  deliveries  in  which  ether 
was  used  in  all  toxemic  cases  there  were  only  71  cases  of  eclampsia. 

Another  question  presenting  itself  was  whether  chloral  hydrate,  a 
drug  we  were  using  extensively  in  eclampsia  both  to  lower  blood-pressure 
and  quiet  the  nervous  system,  had  like  cliloroform,  which  it  somewhat 
resembled  chemically  and  in  name,  a  deleterious  effect  upon  the  liver 
and  kidneys.  At  the  author's  suggestion,  Dr.  J.  Gardner  Hopkins,^ 
at  that  time  Pathologist  to  the  Sloane  Hospital,  undertook  a  series  of 
experiments  to  solve  this  problem.  In  these  experiments  it  was  attempted 
to  produce  the  severest  effects  possible  from  chloral  hydrate,  and  doses 
were  given  sufficient  to  produce  surgical  anesthesia.  To  do  this  large 
amounts  of  chloral  had  to  be  used  and  a  number  of  dogs  died  without 
recovering  from  the  anesthesia.  A  sufficient  number  recovered,  however, 
from  which  to  study  the  condition  of  the  liver  and  kidneys  after  a  lapse 
of  one  or  two  days,  the  time  at  which  the  lesions  from  cliloroform  are  most 
severe.  In  the  series  of  twenty-six  dogs  poisoned  in  various  ways  by 
chloral,  only  six  were  found  whose  livers  showed  definite  pathological 
changes.  These  changes  consisted  in  the  appearance  of  fat  in  the  liver 
cells.  None  of  the  livers  showed  necrosis  of  the  cells  about  the  central 
veins — the  lesion  characteristic  of  chloroform  poisoning  and  eclampsia. 
The  kidneys  showed  no  histological  changes  produced  by  the  chloral. 

As  a  result  of  these  experiments  one  may  therefore  feel  justified  in 
continuing  the  use  of  chloral  in  eclampsia  without  fear  that  in  reasonable 
doses  it  is  likely  to  do  harm  to  either  liver  or  kidneys. 

Prognosis. — The  prognosis  of  the  toxemia  of  pregnancy  depends  upon 
the  extent  of  the  visceral  lesions,  especially  those  of  the  liver  and  kidneys, 
and  these  depend  largely  upon  the  period  at  which  the  condition  is  recog- 
nized and  treated.  Most  of  the  maternal  deaths  occur  in  those  whose 
urine  has  not  been  regularly  and  frequently  examined  and  whose  general 
condition  has  not  been  constantly  watched  for  early  evidences  of  a 
toxemia  such   as  headache,  vomiting,  high  blood-pressure,  edema,  etc. 

1  A  Study  of  Experimental  Poisoning  with  Chloral  Hydrate  with  References  to  its  Effect 
on  the  Liver  and  Kidneys,  Amer.  Jour.  Obstet.,  April,  1912,  vol.  xxv.  No.  4. 


442  TOXEMIA  OF  PREGNANCY 

It  imist  1)0  admitted,  however,  that  in  a  certain  number  of  cases  after 
exposure  to  cold  or  indiscretion  in  diet,  the  echimptic  seizure  will  be  so 
fulminating  and  with  so  little  warning  as  to  be  beyond  human  knowledge 
to  foresee  or  prevent.  As  indicated  above  also  the  prognosis  depends  a 
good  deal  upon  the  treatment,  although  the  results  in  different  hospitals 
will  depend  largely  upon  the  type  of  patients  received,  i.  e.,  whether  the 
service  is  composed  largely  of  emergency  ambulance  cases,  brought  to 
the  hospital  as  a  last  resort  after  gross  neglect  of  the  patient  at  home, 
or  whether  the  service  is  a  waiting  service  with  patients  kept  under  care- 
ful observation.  Our  present  maternal  mortality  at  the  Sloane  Hospital, 
where  the  service  is  partly  an  emergency  and  partly  a  waiting  one,  is 
about  11  per  cent.,  i.  e.,  in  the  last  71  cases  of  eclampsia  occurring  in 
8000  consecutive  deliveries  there  were  8  deaths,  a  mortality  of  11.2  per 
cent. 

In  the  251  cases  of  eclampsia  in  the  20,000  consecutive  deliveries  at 
the  Sloane  Hospital  there  were  71  maternal  deaths,  or  28.3  per  cent. 
Of  these  251  cases 

159  were  antepartum  with  55  deaths,  or  34.5  per  cent. 
40  were  intrapartum  with  11  deaths,  or  27.5  per  cent. 
52  were  postpartum    with    5  deaths,  or    9.6  per  cent. 

No  one  can  watch  the  rapidity  with  which  the  toxic  symptoms  usually 
disappear  after  the  uterus  is  emptied,  without  being  impressed  with 
the  benefit  of  this  procedure,  whether  induced  by  nature  or  by  art.  A 
glance  at  the  above  statistics  shows  that  while  occasionally  eclampsia 
occurs  postpartum,  its  mortality  is  relatively  low  and  the  prognosis 
therefore  hopeful. 

Fetal  Mortality. — In  the  251  cases  of  eclampsia  occurring  in  the  20,000 
consecutive  deliveries  there  were  151  fetal  deaths,  or  60.15  per  cent.;  of 
these  151,  35  were  prior  to  the  period  of  viability,  89  were  stillbirths  and 
27  died  subsequent  to  birth,  making  116  fetal  deaths  in  216  viable  fetuses, 
a  fetal  mortality  of  53.9  per  cent. 

There  are  several  conditions  affecting  the  life  of  the  fetus  in  the  toxemia 
of  pregnancy  which  deserve  consideration.  In  the  first  place  the  fetus 
shares  the  mother's  toxemia,  and  for  a  given  period  of  gestation  is  less 
well  developed  and  has  less  vitality  than  in  a  normal  pregnancy.  In  the 
second  place  one  of  the  common  accidents  of  a  toxemia  of  pregnancy  is 
an  accidental  hemorrhage  which,  separating  more  or  less  of  the  placenta 
from  the  uterine  wall,  greatly  endangers  fetal  life.  Again,  a  sufficient 
number  of  fetuses  have  been  born  in  a  spastic  state  to  indicate  that  a 
fetus  may  have  an  intra-uterine  convulsion  and  life  become  extinct  at 
that  time.  Finally,  in  the  interests  of  the  mother,  pregnancy  is  usually 
interrupted  on  the  occurrence  of  a  convulsion,  however  premature  the 
gestation  may  be,  and  the  artificial  delivery  coupled  with  the  prematurity 
naturally  gives  a  high  fetal  mortality. 

One  of  the  problems  facing  the  obstetrician  in  the  toxemia  of  preg- 
nancy is  whether,  aside  from  the  mother's  interests,  which  usually  should 
stand  paramount,  the  fetus  has  a  better  chance  of  life  and  development 


THREATENED  ECLAMPSIA   AND  ECLAMPSIA  4^4:3 

by  remaining  longer  in  iifcro  or  by  being  brought  into  the  \\'orld.  The 
risks  of  the  fetus  becoming  more  toxic  or  of  an  accidental  hemorrhage 
occurring  at  any  time  are  so  great  that  often  the  fetal  chances  are  better 
from  an  interruption  of  pregnancy  than  from  its  longer  continuance. 

The  subject  of  a  subsequent  pregnancy,  after  an  eclampsia  and  a 
pregnancy  in  a  patient  known  to  have  a  chronic  nephritis,  now  deserves 
consideration.  Many  women  have  a  fulminating  attack  of  toxemia 
with  eclampsia  are  delivered  and,  while  perhaps  the  urine  diu-ing  the 
attack  nearly  solidified  on  boiling,  it  rapidly  clears  so  that  in  from  two 
to  four  weeks  it  becomes  normal  and  remains  so.  These  cases  under 
proper  supervision  and  careful  regimen  are  often  able  to  go  through 
subsequent  pregnancies  without  further  kidney  trouble. 

On  the  other  hand,  a  certain  number  of  cases  of  toxemia  with  or  with- 
out eclamptic  seizures,  continue  to  show  urinary  changes  for  a  long 
time  after  apparent  recovery  from  the  toxemia.  There  is,  perhaps,  a 
continuous  albuminuria  for  several  months  and  after  that  if  the  patient 
gets  overfatigued  or  catches  cold  a  little  albuminuria  returns.  More- 
over, a  few  casts  are  frequently  present  and  the  patient  shows  that  her 
kidneys  have  ne^'er  quite  recovered  from  the  results  of  the  toxemia.  A 
subsequent  pregnancy  in  these  cases  is  always  a  serious  matter.  With 
proper  care,  avoiding  foods  rich  in  proteids  and  keeping  the  avenues  of 
elimination  active,  they  may  be  carried  safely  through  their  pregnancy, 
but  they  are  always  a  source  of  anxiety  to  the  obstetrician,  as  in  many 
of  them  a  toxemia  develops  in  the  latter  half  of  pregnancy  which  may 
require  induction  of  labor  to  control.  In  both  of  these  post-toxemic 
classes  of  women  the  wisest  plan  is  to  advise  them  not  to  become  pregnant 
until  the  urine  has  been  free  from  albumin  for  at  least  a  year. 

If  a  woman  has  a  chronic  diffuse  nephritis  and  marries,  the  danger  of 
pregnancy  should  be  explained  to  her  and  she  should  be  advised  to  avoid 
it.  If  pregnancy  ensues  the  blood-pressure  and  urine  should  be  under 
most  careful  observation  so  that  if  necessary  the  pregnancy  may  be 
interrupted  before  the  kidney  lesion  becomes  too  serious. 


CHAPTER  XIII. 

LOCAL  AND  GENERAL  AFFECTIONS  AND  DISEASES 
COMPLICATING  PREGNANCY. 

Varicosities  and  Hematoma  of  the  Vulva. — As  a  result  of  the  pressure 
of  the  pregnant  uterus  upon  the  ]>el\ic  veins,  varicosities  in  the  lower 
extremities  and  at  the  pelvic  outlet  are  common.  These  varicosities  are 
naturally  greater  in  vertex  presentations  than  in  breech  presentations, 
where  the  pressure  of  the  hard  head  is  absent.  They  are  also  more 
common  in  multiple  pregnancy  than  in  a  single  pregnancy.  ^  aricosities 
are  also  greater  in  cases  which  have  had  a  previous  varicose  condition  of 
the  veins  at  the  beginning  of  pregnancy.  The  results  of  the  pelvic  press- 
ure are  seen  in  varicosities  of  the  vulva,  varicosities  of  the  legs  and 
thighs  and  in  hemorrhoids. 

A'aricosities  of  the  \uha  are  seen  and  felt  as  irregular  worm-like  masses 
in  either  labium,  increasing  in  size  on  standing  and  straining,  giving  to 
the  woman  the  feeling  of  fulness,  weight  and  perhaps  burning,  occasion- 
ally reaching  such  a  size  as  to  interfere  with  walking.  The  importance 
of  the  condition  of  course  rests  on  the  possibility  of  their  rupture  either 
into  the  tissue  of  the  vuha  forming  a  hematoma  of  the  vulva,  or  exter- 
nally, with  marked  hemorrhage.  The  natural  tendency  of  the  \'aricosities 
is  to  steadily  increase  as  pregnancy  advances  and  the  intrapelvic  pressure 
increases,  and  with  the  veins  of  the  bulbs  of  the  vestibule  enormously  dis- 
tended it  requires  but  little  increase  in  the  tension  to  cause  their  rupture, 
as  from  a  fall  astride  a  hard  object,  a  blow,  a  kick,  or  the  straining  of 
labor,  or  e^■en  the  straining  at  stool. 

Hematoma. — The  result  of  the  rupture  of  a  varicocele  (jf  the  vulva 
is  soon  seen  in  a  rapidly  developing  tumor  of  the  vulva,  which  as  a  rule 
soon  assumes  on  its  inner  aspect  the  bluish  discoloration  characteristic 
of  ecchymoses.  If  the  skin  of  the  vulva  is  unbroken  the  hemorrhage 
occurring  into  a  confined  space  usually  soon  ceases  spontaneously,  but 
if  from  any  trauma  the  skin  of  the  vulva  is  broken,  the  hemorrhage  may 
be  so  severe  as  to  endanger  the  life  of  the  woman.  The  size  of  the  dis- 
tendedlabium  may  become  so  great  as  to  form  a  tumor  causing  dystocia, 
as  will  be  referred  to  again  under  that  head. 

Treatment. — Prophylactic. — The  object  sought  in  treating  this  con- 
dition is  first  to  prevent  as  far  as  possible  the  increase  in  size  of  the 
varicosities  by  reducing  the  amount  of  pressure  from  above  and  giving 
suj)port  to  the  dilated  veins  below.  Although  it  is  impossible  to  entirely 
remove  the  pressure  from  above  until  the  termination  of  the  pregnancy, 
something  can  be  accomplished  by  having  the  patient  wear  a  long,  well- 
fitting  corset,  which  comes  well  beneath  the  abdominal  tumor  and  sup- 
(444) 


VARICOSITIES  OF   THE  LEGS  AND   THIGHS  445 

ports  it,  in  fact  lifts  it  from  the  pelvic  veins.  Another  measure  of  relief 
is  to  make  sure  that  the  lower  bowel  is  kept  empty  so  as  to  avoid  the 
pressure  of  any  fecal  column. 

The  best  support  to  the  dilated  veins  of  the  vulva  is  usually  obtained 
by  having  the  patient,  when  she  is  on  her  feet,  wear  a  firm,  soft  vulva  pad 
or  napkin.  Furthermore,  every  woman  suffering  with  marked  dilatation 
of  the  veins  of  the  vulva  should  be  warned  of  the  possibility  of  their 
rupture  and  be  instructed  that  in  case  this  occurs,  she  should  lie  down 
at  once  and  apply  pressure,  assuring  her  that  if  she  will  do  this  and 
summon  her  physician,  nothing  serious  will  happen  before  his  arrival. 
If  the  skin  of  the  vulva  is  unbroken  the  best  treatment  is  rest  in  the  hori- 
zontal position  with  an  ice-bag  applied  to  the  vulva.  If  the  skin  is  broken 
it  is  often  advisable  for  the  obstetric  surgeon  to  incise  the  hematoma, 
turn  out  the  clots,  introduce  a  purse-string  suture  around  the  bleeding 
surface  and  pack  the  remaining  cavity  with  gauze.  This  last  is  the 
treatment  recommended  when  the  vulvar  hematoma  serves  as  a  cause 
of  dystocia,  as  will  be  seen  later. 


~Wi 

^^K'      "^^■■HHH 

l^p r....,.»:,,.,.,,.«....... 

J^^^^^^^^^^t^    -V 

^^^^^^^^HHjHp  " 

u 

i^^^^^^^K'            4I 

Fig.  307. — Varicosities  of  the  thighs  in  pregnancy. 

Varicosities  of  the  Legs  and  Thighs.— With  the  tendency  among 
non-pregnant  woman  to  have  varicose  veins  on  the  leg  or  thigh  as  great 
as  it  is,  it  is  easy  to  understand  why,  in  pregnancy  with  pressure  upon 
the  pelvic  veins  from  the  pregnant  uterus  and  the  frequency  of  constipa- 
tion, these  varicosities  are  common.  A  marked  case  is  shown  in  Fig. 
307.  In  order  to  avoid  marked  permanent  dilatation  of  the  veins  of  the 
lower  extremities  with  the  accompanying  discomforts,  it  is  always  wise 
to  support  the  dilated  veins  with  an  elastic  stocking  or  well-fitting  ban- 
dage. Occasionally  a  group  of  dilated  veins,  as  in  the  calf  or  in  the 
popliteal  space,  becomes  inflamed  and  extremely  tender  during  preg- 
nancy. This  antepartum  phlebitis  is  treated  in  the  same  way  as  that 
of  the  postpartum  variety  with  rest  in  the  horizontal  position,  the  appli- 
cation of  an  ice-bag  and  later  support. 


446     AFFECTIONS  AXD  DISEASES  COMPLICATING  PREGNANCY 

Hemorrhoids. — Another  result  of  obstructed  venous  circulation  from 
pelvic  i)ressure  in  pre^^nancy  is  seen  in  the  frequent  occurrence  of  hemor- 
rhoids, which  may  add  greatly  to  the  discomfort  of  the  patient.  The 
majority  of  women  are  constipated  during  pregnancy  and  this  con.stipa- 
tion,  together  with  the  pressure  of  the  pregnant  uterus,  naturally  jiredis- 
poses  to  a  dilatation  of  the  hemorrhoidal  veins. 

Treatment. — The  treatment  is  prophylactic  and  j)alliative,  seldom  radi- 
cal during  pregnancy.  The  prophylactic  treatment,  consists  in  keeping 
the  bowels  moving  regularly  each  day  and  in  taking  the  pressure  off 
from  the  pelvic  veins  as  much  as  possible  by  the  use  of  a  well-fitting 
corset  or  an  abdominal  bandage. 

The  palliative  treatment  usually  employed  by  the  author  is  as  follows: 
After  each  stool  have  the  patient  bathe  the  anus  with  cold  water.  After 
drying  the  parts  have  her  apply  with  toilet  paper  some  of  the  following 
ointment,  carrying  a  little  of  it  into  the  bowel. 

I^ — Ichthyol 5ij 

Ointment  of  tannic  acid           ...  ov 

Lanolin .       .  oJ 

If  the  hemorrhoids  are  acutely  inflamed,  rest  in  bed  with  local  ap])lica- 
tions  of  cold  witch  hazel  reduces  the  inflammation  and  gi^■es  marked 
relief.  It  is  seldom  advisable  to  remove  the  hemorrhoids  by  operation 
during  pregnancy. 

Edema  of  the  Vulva. — This  may  be  of  three  different  varieties.  It 
may  be  (a)  systemic,  (b)  mechanical  or  (c)  the  result  of  local  inflam- 
mation. 

(a)  Systemic. — An  edema  of  any  part  of  the  body  in  pregnancy  may  be 
an  expression  of  a  toxemia  with  deficient  kidney  function.  Hence  the 
appearance  of  edema  of  the  vulva  should  always  indicate  first  of  all  an 
examination  of  the  urine.  Should  this  be  found  abnormal  the  condition 
should  be  looked  upon  as  systemic  and  the  treatment  indicated  is  that 
of  toxemia.  If  the  urine  is  found  normal,  grave  anxiety  ceases  and  it 
can  be  concluded  that  the  condition  is  local. 

(h)  Mechanical. — A  common  result  of  the  intrapelvic  pressure  in  preg- 
nancy is  edema  of  the  vulva  and  lower  extremities.  With  the  urine 
normal,  this  may  usually  be  looked  upon  as  of  little  consequence  save 
discomfort.  This  edema  of  the  vulva  may  be  either  unilateral  or  bilateral 
(see  Fig.  308).  It  may  be  so  pronounced  as  to  cause  considerable 
discomfort  and  under  these  circumstances  it  may  be  wise  to  put  the 
patient  to  bed  for  a  time.  The  horizontal  position  with  the  use  of  hot 
applications  will  usually  reduce  the  edema  markedly.  In  a  few  cases 
it  is  well,  after  carefully  disinfecting  the  skin  of  the  vulva,  to  prick  it  in 
several  places  with  a  sterile  needle  and  allow  the  serum  to  drain  away. 

After  this  slight  operation  the  vulva  must  be  kept  carefully  covered 
with  a  sterile  dressing  on  account  of  the  danger  of  infection. 

(c)  The  Result  of  Local  Infection. — Occasionally  an  edema  of  the  vulva 
may  be  caused  by  a  local  infection  and  inflammation,  as  a  gonorrheal 
vaginitis  and  ^'ulvitis,  a  chancroid,  or  an  abscess  of  one  of  the  vulvo- 


GONORRHEAL  INFECTION 


447 


vaginal  glands.  A  careful  inspection  and  a  smear  will  usually  establish 
the  diagnosis  and  the  treatment  is  that  of  an  infection. 

Edema  of  the  lower  extremities  will  be  considered  here  as  it  is  so  inti- 
mately associated  with  edema  of  the  vulva.  As  with  the  latter  condition 
it  may  be  of  very  serious  import  or  of  very  little  consequence.  It  may  be 
one  of  the  early  symptoms  of  a  serious  toxemia  or  it  may  be  purely 
mechanical. 

Examination  of  the  urine  tells  the  story,  hence  the  importance  of 
instructing  all  pregnant  patients  to  report  the  presence  of  any  edema. 
If  examination  of  the  urine  shows  it  to  be  normal,  they  can  safely  be 
informed  that  the  swelling  is  simply  from  pressure. 


Fig.  308. — Edema  of  the  vulva  in  pregnancy. 


Gonorrheal  Infection. — Gonorrheal  infection  of  the  vulva,  urethra, 
vagina  and  cervix  will  be  discussed  together,  as  in  practice  they  are 
usually  found  associated. 

While  it  is  possible  for  the  woman  to  infect  herself  by  using  an  infected 
towel  or  napkin,  the  usual  source  is  sexual  intercourse  with  an  infected 
man. 

To  the  shame  of  the  husband  be  it  said  that  the  lessened  frequency  of 
intercourse  usually  practised  during  pregnancy  is  regarded  by  some  a 
sufficient  excuse  for  his  seeking  gratification  outside,  with  the  natural 
result  of  an  infection  which  he  communicates  to  his  wife  on  his  return. 

The  danger  of  puerperal  infection  at  her  delivery,  to  say  nothing  of 
added  discomforts  during  pregnancy,  and  the  risk  of  ophthalmia  in  the 
case  of  the  child,  make  this  infection  a  very  serious  one. 


448       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

Diagnosis. — A  gonorrheal  infection  during  pregnancy,  with  its  asso- 
ciated, increased  vascularity,  usually  presents  a  very  acute  picture.  The 
edema,  the  purulent  discharge,  gluing  the  hairs  of  the  vulva  together; 
the  presence  of  pus  in  the  urethra,  perhaps  in  Skene's  ducts;  the  inflamed 
openings  of  the  ducts  of  the  vulvo^•aginal  glands;  the  frequent  mic- 
turition and  tenesmus;  all  suggest  the  diagnosis  of  infection  by  the 
gonococcus  and  a  smear  will  verify  it. 

Treatment. — The  importance  of  curing  the  condition  if  possible,  before 
the  onset  of  labor,  indicates  active  local  treatment.  In  the  author's 
experience,  daily  douches  by  the  patient  of  bichloride  solution  (1  to  5000) 
and  daily  applications  by  the  obstetrician  of  25  per  cent,  argyrol  solution 
to  cervix,  vagina,  urethra,  and  all  crypts  within  the  vulva  have  given  the 
best  results. 

At  the  time  of  the- labor  a  careful  irrigation  of  the  vagina  with  0.5  per 
cent,  lysol  solution  lessens  the  danger  of  infection  of  the  baby's  eyes,  but 
as  soon  as  it  is  born  its  eyes  should  be  thoroughly  irrigated  with  a  satu- 
rated solution  of  boric  acid  and  25  per  cent,  solution  of  argyrol  or  1  per 
cent,  solution  nitrate  of  silver  instilled.  ]\Iy  own  preference  is  for  25 
per  cent,  solution  of  argyrol  repeated  every  four  hours  for  the  first  three 
days  of  the  baby's  life. 

As  regards  the  treatment  of  the  parturient  canal  after  the  birth  of 
the  child,  the  best  plan  in  the  writer's  judgment  is  to  avoid  all  postpartum 
douches  on  account  of  the  danger  of  carrying  the  infection  higher,  and  to 
be  content  with  especial  care  in  maintaining  the  cleanliness  of  the  vulva. 

The  possibility  of  puerperal  infection  with  a  complicating  salpingitis 
or  oophoritis  should  always  be  borne  in  mind,  but  this  danger  is  not 
lessened  by  postpartum  douches,  but  rather  increased. 

Abscess  of  Vulvovaginal  Gland. — A  great  many  chaste  women  as  a 
result  of  a  simple  catarrlial  inflammation  of  the  vulva  near  the  opening 
of  one  of  the  vulvovaginal  or  Bartholin's  glands,  have  a  cyst  in  either 
labium.  The  most  common  cause  of  an  al)scess  of  this  gland  is  a  gonor- 
rheal infection  rather  than  a  simple  catarrhal  inflammation  or  trauma. 
However,  not  infrequently  an  abrasion  of  a  cyst  of  this  gland  leads  to  an 
infection  of  it  with  the  ordinary  pathogenic  organisms  found  about  the 
vulva,  as  the  colon  bacilli,  staphylococci,  etc.,  and  an  abscess  results 
without  the  presence  of  gonococci. 

Treatment. — As  it  is  very  desirable  to  eliminate  as  far  as  possible  all 
sources  of  infection  about  the  parturient  canal  before  the  onset  of  labor, 
the  best  treatment  of  an  abscess  of  the  vulvovaginal  gland  complicating 
pregnancy  is  incision  as  soon  as  the  diagnosis  is  made,  so  that  the  abscess 
cavity  will  either  be  healed  or  at  least  granulating  before  labor.  The 
redness,  edema  and  tenderness  of  the  labium  usually  enables  the  diag- 
nosis of  abscess,  from  a  cyst  of  Bartholin's  gland,  to  be  made  without 
difficulty. 

Pruritus  Vulvae. — The  increased  secretion  of  the  vagina  and  vulva, 
common  in  pregnancy,  especially  in  the  obese,  often  gives  rise  to  a 
pruritus,  perhaps  even  to  an  eczema  of  the  vulva,  which  may  be  very 
distressing  and  interfere  with  sleep. 


PROLAPSE  OF  THE  VAGINAL  WALLS  449 

Treatment. — The  first  step  in  the  treatment  of  the  pruritus  is  to  ascer- 
tain whether  the  source  of  the  irritation  is  from  above,  as  from  a  vagina] 
discharge  or  a  septic  or  diabetic  urine,  or  from  without,  as  from  parasites 
or  filth. 

If  an  irritating  urine  is  present  this  should  receive  its  appropriate  treat- 
ment and  the  same  may  be  said  of  parasites  or  filth.  If  the  itching  is 
due  to  a  simple,  though  increased  vaginal  leucorrhea,  as  a  rule  on  account 
of  the  risk  of  carrying  infection  into  the  vagina  or  lessening  nature's 
safeguards  against  infection,  douching  should  not  be  advised.  If,  under 
exceptional  circumstances  a  douche  is  used,  one  containing  borax,  a 
tablespoonful,  and  alum,  a  teaspoonful,  in  two  quarts  of  warm  water  is  to 
be  preferred. 

The  author's  ordinary  procedure  is  to  direct  the  patient  to  bathe  the 
vulva  frequently,  i.  e.,2  or  3  times  in  the  twenty-four  hours  with  carbolic 
solution  (1  to  100).  This  usually  affords  great  relief.  If,  either  as  a  result 
of  the  itching  and  scratching,  or  as  a  result  of  a  constitutional  dyscrasia, 
an  eczema  of  the  vulva  is  present,  the  following  ointment  is  of  value: 

3 — ^Acidi  salicylici gr.  xv 

Zinci  oxidi, 

Pulv.  amyli aa      5iiss 

Petrolati SJ 

M.  Sig.  apply  locally. 

To  this  ointment,  as  the  process  becomes  less  acute,  the  oil  of  cade,  5  j> 
is  added. 

Pruritus  vulvse  is  sometimes  only  a  part  of  a  general  pruritus  resulting 
from  a  toxemia,  a  gouty  diathesis,  or  a  neurasthenia  and  in  these  the 
general  condition  needs  treatment  as  well  as  the  local. 

Pointed  Condylomata  or  Venereal  Warts. — These  are  usually  of  gonor- 
rheal origin,  but  occasionally  develop  as  a  result  of  irritation,  due  to 
the  increased  secretion  of  the  parts  in  pregnancy  even  in  chaste  indi- 
viduals. As  the  result  of  the  marked  vascularity  of  the  vagina  and  vulva 
these  pointed  condylomata  usually  grow  very  luxuriantly,  but  unless 
they  show  a  tendency  to  slough  it  is  usually  better  to  postpone  their 
removal  until  after  delivery.  As  sloughing  would  interfere  with  an  aseptic 
technic  removal  is  indicated  in  this  condition,  although  they  bleed 
more  in  removal  during  the  pregnant  than  in  the  non-pregnant  state. 

As  a  rule  cleanliness  and  the  use  of  a  dessicating  powder,  as  calomel, 
starch,  talcum,  etc.,  singly  or  combined,  serves  the  purpose  well. 

Prolapse  of  the  Vaginal  Walls. — If  the  patient  has  previously  been 
the  subject  of  a  cystocele  or  rectocele,  these  conditions  are  usually  much 
aggravated  by  the  weight  and  pressure  of  the  pregnant  uterus  and  by  the 
constipation  which  so  often  accompanies  pregnancy.  Occasionally  in 
primigravidse  this  weight  and  pressure  combined  with  straining  at  stool 
are  sufficient  to  originate  this  prolapse  of  the  vaginal  walls. 

Cystocele. — Of  the  two  vaginal  walls  the  prolapse  of  the  anterior 
wall  together  with  the  bladder  attached  to  it  is  the  more  important. 
This  cystocele  sometimes  produces  such  a  pouch  filled  with  urine  as 
29 


450      AFFECTIONS  AXD  DISEASES  COMPLICATING  PREGNANCY 

practically  to  fill  the  vagina  and  even  project  from  it.  The  patient  suffers 
with  the  feeling  of  weight  and  pressure  in  the  vagina  with  retention  of 
urine  and  vesical  tenesmus.  The  best  treatment  in  this  pronounced  type 
of  case  is  to  catheterize  the  patient,  putting  her  in  the  knee-chest  posi- 
tion, if  necessary,  to  relieve  the  pressure  of  the  presenting  part  upon  the 
bladder.  To  avoid  a  recurrence  of  the  trouble  it  is  usually  wise  to  support 
the  abdomen  with  a  well-fitting,  long  corset  and  have  the  patient  assume 
the  knee-chest  position  for  a  few  moments  night  and  morning.  In  a  few 
cases  it  is  necessary  to  hold  up  the  vaginal  wall  with  a  ring  pessary, 
although  the  author  dislikes  very  much  to  have  any  foreign  body  in  the 
vagina  during  the  last  month  of  pregnancy  lest  it  interfere  with  nature's 
safeguard  against  infection. 

Prolapse  of  the  Pregnant  Uterus. — \Mien  a  prolapsed  uterus  becomes 
pregnant,  although  at  first  the  trouble  is  increased  by  the  extra  weight 
of  the  organ,  as  the  pregnancy  advances  the  rule  is  that  the  uterus  gradu- 
ally rises  into  the  abdomen  and  the  woman  does  not  suffer  again  from  her 
prolapse  until  after  delivery. 

On  the  other  hand  in  exceptional  cases  the  prolapse  increases  during 
the  pregnancy  or  even  originates  during  the  pregnancy  from  lack  of 
support  in  the  pelvic  floor  and  increased  pressure  from  above.  This 
prolapse  may  increase  to  such  an  extent  as  to  interfere  with  micturition 
and  defecation,  to  make  standing  and  walking  impossible,  and  even  to 
the  extent  of  incarceration  outside  the  pelvic  outlet,  a  condition  which 
if  unreduced  almost  inevitably  leads  to  abortion.  The  diagnosis  is 
usually  easy,  although  unless  the  height  of  the  fundus  is  carefully  noted, 
an  hypertrophy  of  the  cervix,  with  a  rectocele  and  cystocele  might  be 
taken  for  a  prolapse  of  the  uterus  as  a  whole. 

Treatment. — The  treatment  in  cases  where  the  cervix  is  outside  the 
vulva  consists  first  in  putting  the  woman  to  bed  and  keeping  the  uterus 
in  place  in  the  hope  that  as  the  uterus  enlarges  its  increased  size  and 
that  of  the  fetus  will  prevent  the  recurrence.  In  some  cases  rest  in  the 
horizontal  position  will  accomplish  this.  In  other  cases  elevation  of  the 
foot  of  the  bed  is  indicated,  and  in  still  other  cases  some  vaginal  support 
as  a  pessary  or  tampon  is  necessary,  although  it  must  be  remembered 
that  any  tamponade  of  the  vagina  in  pregnancy  favors  its  interruption. 

In  some  cases  the  tendency  to  a  recurrence  of  the  prolapse  is  so  great 
that  during  the  last  weeks  of  the  pregnancy  the  patient  has  to  be  kept  in 
bed  most  of  the  time,  allowing  her  up  for  a  period  of  a  few  hours  with 
the  support  of  a  firm  T  bandage. 

Retroversion  and  Sacculation  of  the  Uterus. — These  conditions  are 
also  discussed  under  Dystocia  and  will  not  be  considered  here. 

Bands  and  Septa  in  the  Vagina. — These  may  have  considerable  in- 
fluence upon  labor,  but  as  a  rule  have  no  effect  during  pregnancy,  hence 
they  Avill  he  discussed  under  the  head  of  Dystocia  from  the  Soft  Parts. 

Carcinoma  of  the  Cervix. — Occasionally  a  malignant  disease  of  the 
cervix  complicating  pregnancy  is  met  with.  In  such  cases,  as  always  in 
pregnancy,  the  life  of  the  mother  should  receive  first  consideration.  The 
pregnancy  should  be  interrupted  promptly  if  the  case  is  operable  and 


SALPINGITIS  451 

the  uterus  and  pelvic  glands  should  be  removed.  If  the  child  is  viable, 
a  Cesarean  section  just  preceding  the  hysterectomy  is  usually  the  method 
of  choice. 

Fibromyomata. — Fibromyomata  complicating  pregnancy  are  discussed 
under  Dystocia  (see  page  630).  Suffice  it  to  say  here  that  unless  they 
are  pedunculated  and  so  situated  as  to  be  likely  to  cause  dystocia  they 
are  not,  as  a  rule,  to  be  interfered  with  during  pregnancy. 

Salpingitis. — As  a  rule  salpingitis  is  bilateral  and  causes  sterility,  for 
even  if  the  content  of  the  tube  has  become  sterile  the  fimbriated  extremi- 
ties are  usually  occluded,  rendering  the  union  of  the  ovum  and  spermato- 
zoon impossible. 

Occasionally,  however,  a  salpingitis  is  unilateral  and  pregnancy  through 
the  healthy  tube  is  possible,  or  infection  and  impregnation  may  occur 
at  about  the  same  time.  Hence  it  is  possible  to  have  a  pregnancy  com- 
plicated by  either  a  chronic  or  an  acute  salpingitis  and  as  a  result  of 
the  stretching,  pressure  and  trauma  of  pregnancy  and  labor  a  chronic 
salpingitis  may  undergo  an  exacerbation,  so  that  a  pyosalpinx  may 
complicate  pregnancy  or  the  puerperium. 

Symptoms. — The  symptoms  of  a  salpingitis  complicating  a  pregnancy 
vary  with  the  chronicity  of  the  inflammation.  If  the  process  is  old  and 
the  tubal  content  sterile  the  only  symptom  usually  present  is  pain 
caused  by  the  stretching  of  the  old  adhesions  about  it.  Occasionally 
there  may  be  added  the  symptoms  of  a  threatened  abortion  on  account 
of  the  normal  expansion  of  the  uterus  being  interfered  with  by  old  adhe- 
sions binding  uterus  and  tubes  in  the  pelvis.  If  the  process  is  acute  or 
an  acute  exacerbation  of  a  chronic  salpingitis  there  are  present  the  rise 
of  temperature  and  pulse,  the  pain  and  tenderness,  the  nausea,  the  bladder 
irritability,  the  tympanites,  etc.,  usually  associated  with  an  acute  salpin- 
gitis with  pelvic  peritonitis. 

If  a  pus  sac  has  formed  this  may  project  itself  against  the  abdominal 
wall  or  bulge  into  the  vaginal  fornix.  If  the  abscess  sac  by  traction  of 
the  growing  uterus  or  the  trauma  of  labor  is  ruptured  there  may  be  added 
the  symptoms  and  signs  of  a  spreading  peritonitis. 

Diagnosis. — The  positive  diagnosis  of  a  salpingitis  of  the  right  side  com- 
plicating a  pregnancy  is  sometimes  difficult.  The  symptoms  and  even 
the  physical  signs  may  resemble  those  of  appendicitis.  In  fact,  both  con- 
ditions may  be  present,  either  one  having  been  the  seat  of  the  original 
focus  of  inflammation,  which  then  spread  to  the  other.  If  only  a  salpin- 
gitis is  present  the  diagnosis  can  usually  be  made  by  the  history  of 
previous  pelvic  inflammation,  the  feeling  of  an  elongated,  tender  mass 
extending  to  the  horn  of  the  uterus;  this  elongated,  tender  mass  felt 
through  the  vagina  usually  lying  lower  than  an  inflamed  appendix.  If 
the  salpingitis  is  of  gonorrheal  origin  evidences  of  this  infection  will 
usually  be  visible  in  Skene's  ducts  or  the  ducts  of  the  vulvovaginal 
glands.  The  temperature,  pulse  and  blood  count  may  be  similar  in  both 
salpingitis  and  appendicitis.  Gastric  disturbances  are  more  marked  in 
appendicitis  than  in  salpingitis.  The  rigidity  of  the  right  rectus  is  more 
marked,  as  a  rule,  in  appendicitis  than  in  right-sided  salpingitis,  but  as  men- 


452       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

tioned  in  the  discussion  of  appendicitis,  rigidity  of  the  recti  muscles  are 
often  less  evident  as  diagnostic  features  in  pregnancy  on  account  of  the 
enlarging  uterus  occupying  the  lower  part  of  the  abdomen.  If  the  sal- 
pingitis is  left-sided  the  elongated  tender  mass  reaching  to  the  left  horn 
of  the  uterus  and  felt  in  the  left  vaginal  fornix,  especially  when  coupled 
with  the  history  of  previous  pelvic  inflammation,  usually  makes  the 
diagnosis  easy. 

Treatment. — The  treatment  of  a  salpingitis  during  pregnancy  and  the 
puerperium  should  in  general  be  conservative.  During  pregnancy  rest 
with  the  application  of  an  ice-bag  over  the  affected  tube,  together  with 
proper  diet,  moving  the  bowels  by  enemata,  etc.,  is  usually  all  that  is 
required. 

If  a  pus  sac  forms  this  should  be  evacuated  and  drained  early  so  that 
if  possible  the  sinus  will  have  healed  before  the  onset  of  labor  in  order 
to  lessen  the  risk  of  infection.  If  there  is  doubt  whether  the  condition 
is  a  salpingitis  or  an  appendicitis,  the  abdomen  should  be  opened  (prefer- 
ably along  the  outer  border  of  the  rectus  muscle)  and  the  pus  sac  re- 
moved. 

During  the  puerperium,  if  an  acute  salpingitis  or  an  acute  exacerbation 
of  a  chronic  salpingitis  develops,  a  certain  amount  of  time  should  be 
given  to  palliative  treatment,  as  rest,  ice-bag,  etc.  But  if  in  spite  of  this 
treatment,  the  condition  as  shown  by  temperature  and  size  of  tumor 
mass  seems  to  be  getting  worse,  operation  should  be  performed  and  the 
pus  sac  removed  if  possible,  otherwise  drained. 

Ovarian  Tumors. — These  are  discussed  in  the  chapter  on  Dystocia  (see 
page  639) ,  but  it  may  be  stated  here  that  unless  the  tumor  is  very  small 
the  best  procedure  is  usually  to  remove  it  early  in  pregnancy  wdth  the 
hope  that  the  pregnancy  will  not  be  interrupted.  In  this  way  not  only 
is  the  risk  of  dystocia  from  it  avoided,  but  the  risk  of  a  twist  in  its  pedicle 
and  the  risk  of  sloughing  and  infection. 


DISEASES    OF   THE    SKIN   IN   PREGNANCY. 

Excessive  Pigmentation. — While  a  certain  increase  in  pigmentation 
of  the  skin  is  characteristic  of  pregnancy,  especially  the  primary  and 
secondary  areolae  of  the  breasts  and  the  darkening  of  the  linea  alba,  in 
some  instances  there  is  such  a  deposit  of  pigment  upon  the  face  as  to  be 
distinctly  disfiguring  (see  Fig.  109).  The  deposit  is  chiefly  upon  the 
forehead  and  cheeks,  while  the  eyelids  remain  of  a  much  lighter  color. 

This  gives  a  peculiar  mask-like  appearance  which  so  alters  the  expres- 
sion of  the  patient  that  she  usually  desires  to  avoid  observation.  She  and 
her  husband  are  often  mentally  distressed  lest  the  disfigurement  be  per- 
manent, but  she  can  be  reassured  that  it  will  rapidly  lessen  after  delivery 
and  will  soon  not  be  noticeable.  It  must  be  admitted,  however,  that  it 
is  likely  to  recur  with  each  pregnancy,  and  there  is  a  little  tendency  for 
the  skin  to  remain  of  a  slightly  darker  hue.  Treatment  of  the  condition 
has  thus  far  been  very  unsatisfactory. 


DISEASES  OF  THE  SKIN  IN  PREGNANCY  453 

Pruritus. — The  local  pruritus  vulvse  has  already  been  studied.  A 
general  pruritus  as  a  result  of  a  toxemia  or  general  neurasthenia  is  not 
at  all  uncommon  in  pregnancy,  and  often  a  source  of  great  discomfort 
to  the  patient,  preventing  sleep  and  increasing  her  neurosis,  which  in 
turn  increases  the  pruritus. 

Treatment. — ^The  general  principles  which  should  govern  the  treatment 
are  methods  favoring  elimination,  nerve  sedatives  and  general  tonics. 
As  in  the  majority  of  cases  the  cause  is  toxemic,  the  bowels  should  be 
moved  freely  with  a  saline  laxative,  the  diet  should  be  of  a  variety  most 
easily  digested,  and  the  secretion  of  urine  should  be  stimulated  by  drinking 
freely  of  water.  For  temporary  relief  a  soda  bath,  adding  a  handful  of 
bicarbonate  of  soda  to  the  tub,  will  often  ^ive  marked  relief.  Building  up 
the  general  system  with  plenty  of  fresh  air,  with  the  administration  of 
iron  and  arsenic,  will,  as  a  rule,  greatly  assist  the  local  treatment. 

Herpes  Gestationis. — ^A^ery  frequently  in  pregnancy,  as  a  result  of  a 
toxemia,  various  skin  lesions  appear  which  have  been  grouped  under  the 
general  term  of  "herpes  gestationis"  although  the  same  lesions  may 
occur  in  the  non-pregnant  and  would  be  better  described  by  the  terms 
erythema  multiforme  or  dermatitis  herpetiformis.  The  lesions  vary  from 
a  smooth  erythema  without  infiltration  to  hardened  papules,  vesicles 
and  even  bullae  on  a  red,  infiltrated  base. 

Symptoms. — ^The  local  symptoms  are  those  of  burning  and  itching.  At 
different  times  the  eruption  may  occur  on  the  thighs,  the  trunk,  the  fore- 
arms, or  even  be  general.  The  eruption  may  resemble  measles  and  scarlet 
fever,  but  the  absence  of  the  constitutional  symptoms  of  these  infectious 
diseases,  the  fact  that  the  eruption  does  not  involve  the  mucous  mem- 
branes, and  that  the  temperature,  if  at  all  elevated,  is  ver}^  slight,  usually 
enables  the  diagnosis  to  be  easily  made.  Although  the  condition  usually 
rapidly  improves  after  delivery,  it  is  very  rarely  severe  enough  to  justify 
interruption  of  pregnancy  unless  this  is  indicated  from  other  evidences 
of  the  toxemia. 

Treatment. — The  treatment  indicated  is  first  of  all  that  of  the  toxemia 
by  the  usual  methods  of  assisting  elimination,  followed  by  general  tonics. 
For  the  relief  of  the  local  irritation  soda  baths,  Lassar's  paste,  carbolic 
solution,  etc.,  may  be  tried. 

Impetigo  Herpetiformis. — One  of  the  rare  skin  affections  occasionally 
complicating  pregnancy  is  impetigo  herpetiformis.  Attention  was  called 
to  it  and  its  high  mortality  by  Hebra  in  1872.  The  eruption  usually 
begins  on  the  inner  side  of  the  thighs  or  in  the  anogenital  region,  and  may 
spread  over  the  trunk  involving  the  mucous  membranes  as  well.  The 
lesion  appears  as  groups  of  pustules  which  spread  peripherally.  These 
groups  often  coalesce,  become  covered  with  large  crusts,  which  then  fall 
off  leaving  perhaps  large,  bleeding,  reddened  areas.  The  centres  of  these 
areas  often  show  efforts  at  healing  while  the  process  is  spreading  at  the 
periphery. 

Symptoms. — The  mucous  membrane  of  the  mouth  may  be  affected 
early.  The  general  condition  of  the  patient  is  depressed,  usually  but  not 
always  accompanied  by  a  rise  of  temperature  and  pulse,  sometimes  with 


454       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

rigors.  In  about  75  per  cent,  of  the  cases,  the  disease  has  proved  fatal. 
The  disease  is  regarded  as  of  toxemic  origin,  although  sometimes 
associated  with  infection. 

Treatment. — Treatment  has  been  of  very  little  avail,  but  with  our 
present  knowledge  of  the  disease  should  be  directed  toward  the  support- 
ing of  the  patient  and  favoring  elimination.  The  ammoniated  mercury 
ointment,  found  so  useful  in  treating  impetigo  in  children,  may  well  be 
tried  as  a  local  application. 

Fibroma  MoUuscum. — Fibroma  molluscum  may  occur  in  pregnancy 
as  in  the  non-pregnant  state.  Brickner^  has  described  such  a  case  and 
states  that  fibroma  molluscum  gravidarum  differs  in  no  way  histologi- 
cally from  the  disease  when  found  in  males  or  in  non-pregnant  women. 
The  disease  is  found  chiefly  about  the  neck  and  under  the  breasts.  It 
is  most  apt  to  appear  in  the  latter  half  of  pregnancy.  While  it  might  be 
thought  the  fibromata  mollusca  might  be  confused  with  warts  or  verrucse, 
the  shape,  consistency  and  peculiar  pedunculation  suffice  to  distinguish 
them. 

The  prognosis  is  absolutely  good,  the  lesions  gradually  disappearing 
spontaneously  a  few  months  after  delivery.  If  the  growths  are  annoying, 
they  may  be  snipped  off  with  a  sharp,  curved  scissors. 

Other  Skin  Diseases. — A  woman  who  is  pregnant  is  liable  to  the  skin 
afi'ections.  to  which  the  non-pregnant  woman  is  subject  and  on  account 
of  the  tendency  to  toxemia  in  pregnancy  all  skin  diseases  which  are  of 
toxemic  origin  are  favored  by  it,  and  if  present  at  its  onset  are  usually 
aggravated  as  pregnancy  advances. 

DISEASES    OF   THE   NERVOUS    SYSTEM. 

Hysteria. — The  nervous  system  of  most  pregnant  women  is  in  a  state 
of  less  stable  equilibrium  than  in  the  non-pregnant  state.  It  requires 
less  to  upset  this  equilibrium ;  the  result  of  the  upset  is  more  pronounced 
and  the  restoration  of  the  normal  equilibrium  is  more  difficult.  From  this 
it  follows  that  if  a  woman  is  predisposed  to  hysterical  manifestations 
when  not  pregnant,  she  is  much  more  prone  to  them  when  pregnant. 
Many  factors  seem  involved  in  bringing  this  about.  The  existence  of  the 
pregnancy  with  possible  interference  with  other  plans  may  be  a  disap- 
pointment. The  physical  dread  of  labor  and  the  mental  dread  of  the 
responsibility  of  maternity  may  darken  the  horizon.  Furthermore,  the 
effect  of  a  toxemia  or  faulty  metabolism,  seen  so  markedly  in  epilepsy 
in  the  non-pregnant,  may  be  evident  here  in  an  hysterical  outburst. 
Suffice  it  to  say  that  hysteria  in  pregnant  women  is  common;  that  it 
does  not  usually  interfere  with  the  progress  of  the  pregnancy  or  effect 
the  physical  or  mental  development  of  the  child. 

Treatment. — The  treatment  consists  chieflv  in  forbearance  on  the  part 
of  the  husband,  the  family  and  the  obstetrician;  moral  suasion  and  the 
use  of  such  nerve  sedatives  as  the  bromides,  valerian,  etc. 

1  Amor.  Jour.  Obstct.,  1900,  liii,  No.  2,  191-199. 


DISEASES  OF  THE  NERVOUS  SYSTEM  455 

Neuralgia. — In  pregnancy  neuralgia  in  different  parts  of  the  body  is 
extremely  common  and  may  be  looked  upon  as  arising  from  one  or  both 
of  two  causes:  (a)  pressure,  (b)  a  toxemia. 

Pressure. — Neuralgic  pains  in  the  sacral  region  and  extending  down  the 
thighs,  resulting  from  the  pressure  of  the  pregnant  uterus  upon  the  sacral 
nerves  and  those  leaving  the  pelvis,  are  easily  to  be  understood.  They 
usually  increase  wdth  the  growth  of  the  fetus  and  cannot  be  entirely 
relieved  until  the  pressure  is  relieved  by  the  delivery.  The  best  that  can 
be  done  is  usually  to  lift  the  uterus  as  much  as  possible  by  having  the 
patient  wear  a  well-fitting  corset  or  abdominal  belt.  Some  relief  can 
often  be  given  by  having  her  assume  the  knee-chest  position  several  times 
a  day,  thus  allowing  the  uterus  to  be  lifted  by  gravity  from  the  pelvic 
nerves.  It  is  the  writer's  custom  to  tell  patients  assuming  the  knee- 
chest  position  to  remain  in  that  position  long  enough  to  draw  six  long 
breaths.  Another  result  of  the  pressure  of  the  pregnant  uterus  is  seen 
in  the  frequency  with  which  cramps  of  the  muscles  of  the  lower  extremi- 
ties occur.  Cramps  in  the  muscles  of  the  foot  or  of  the  leg  are  often  very 
distressing  to  the  patient,  especially  when  she  is  in  bed  with  shoes  and 
clothing  removed.  Firm  extension  of  the  foot  on  the  leg  will  usually 
relieve  the  cramp  promptly. 

Toxemia. — Neuralgia  in  the  upper  part  of  the  body  of  the  pregnant 
woman  is  also  common  and  can  best  be  explained  by  some  fault  in  metab- 
olism with  a  resulting  toxemia.  Certain  it  is  that  as  a  result  of  faulty 
digestion  and  metabolism  the  teeth  more  readily  undergo  caries  in  preg- 
nancy, and  neuralgia  not  infrequently  results  from  this  caries.  The 
treatment  consists  in  improving  metabolism,  favoring  elimination  by  the 
bowels,  kidneys,  etc.,  and  by  proper  attention  to  the  teeth. 

Neuritis. — Occasionally  in  pregnancy  the  patient  not  only  suffers 
from  neuralgic  pains,  but  one  or  more  regions  show  paralysis,  muscular 
atrophy  and  the  reaction  of  degeneration — a  true  neuritis,  with  the 
usual  symptoms  of  tenderness  and  shooting  pains.  As  already  indicated, 
this  may  either  be  localized  in  a  single  area  or  be  multiple.  As  it  often 
occurs  in  areas  where  the  afferent  nerves  are  not  subjected  to  pressure, 
it  is  assigned  to  a  general  dyscrasia,  a  toxemia,  as  its  cause.  This  is 
made  more  probable  from  its  frequent  association  with  other  symptoms 
of  toxemia.  It  usually  disappears  gradually  after  delivery.  The  treat- 
ment is  that  usually  employed  in  neuritis. 

Rarely  is  it  severe  enough  to  justify  interruption  of  the  pregnancy, 
although  occasionally  this  justification  presents  itself. 

Chorea. — If  a  patient  who  has  previously  suffered  from  chorea  becomes 
pregnant  there  is  a  strong  tendency  for  it  to  recur.  Moreover,  chorea 
occasionally  occurs  for  the  first  time  during  pregnancy,  and  may  assume 
a  very  severe  type,  interfering  with  sleep  and  the  taking  of  nourishment. 
The  severe  type  is  associated  with  fever,  mania  and  a  high  mortality. 
In  a  series  of  438  cases  of  chorea  complicating  pregnancy,  collected  by 
Buist,  Schrock,  French  and  Hicks,  there  was  a  mortality  of  16.5  per  cent. 
In  the  mil/d  types  of  chorea  recurring  in  pregnancy  the  cause  may  be  the 
same  as  that  of  the  original  attack  as  anemia,  rheumatism,  a  nerve  shock, 


456     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

etc.,  the  tendency  being  aggravated  pcrhai)s  by  the  unstable  e(iiiiUbrnim 
of  the  nervous  system  in  pregnancy. 

On  the  other  hand  the  severe  tvpe  of  chorea  occurring  for  the  first  time 
in  pregnancy,  characterized  by  the  occurrence  of  fever  during  hfe,  and 
the  autopsy  findings  of  an  acute  endocarditis,  is  usually  assigned  to  a 
toxemia.  In  some  cases  of  a  severe  type  the  Streptococcus  viridans  has 
been  found.  Chorea  usually  appears  in  the  first  half  of  pregnancy  and 
has  a  tendency  to  persist  until  after  delivery,  when  as  a  rule  it  disappears 
spontaneously.  The  severe  types  of  the  disease  often  cause  premature 
delivery. 

Treatment. — In  the  mild  forms  of  the  disease  arsenic,  iron,  rest,  fresh 
air  and  proper  attention  to  the  diet  and  elimination  will  suffice  to  carry 
the  woman  safely  through  her  pregnancy.  If  in  spite  of  this  treatment 
the  condition  persists  and  shows  a  tendency  to  increase,,  the  pregnancy 
should  be  interrupted. 

Insanity  Complicating  Pregnancy  and  the  Puerperium.  Insanity 
During  Pregnancy. — Even  in  a  normal  pregnancy  it  has  been  shown 
that  the  mental  state  of  the  woman  is  in  unstable  equilibrium  and  that 
in  patients  of  the  neurotic  type  it  requires  very  little  to  unbalance 
this  equilibrium,  and  cause  them  to  exhibit  hysterical  manifestations 
and  other  psychoses.  This  disturbed  mental  equilibrium  in  a  certain 
proportion  of  cases,  about  1  to  1000,  amounts  to  a  real  insanity. 

Etiology. — Heredity  and  the  tendency  to  recurrence  are  very  marked 
factors  in  the  etiology  of  the  insanity  of  pregnancy.  If  there  exists  the 
family  taint  of  insanity,  or  if  the  patient  herself  has  ever  been  mentally 
unbalanced,  the  exaggeration  of  all  psychoses,  which  pregnancy  natur- 
ally tends  to  bring  about,  often  acts  to  cause  an  outbreak  or  a  recurrence. 
Occasionally  it  occurs  without  any  known  hereditary  taint  or  previous 
marked  psychosis  in  the  patient.  It  may  show  itself  at  any  time  after 
the  third  month  of  pregnancy  and  is  especially  common  in  the  unmarried 
and  in  those  who  are  not  desirous  of  pregnancy.  It  may  follow  a  marked 
nerve  shock  of  any  description.  Its  onset  is  often  very  insidious  and  may 
be  considered  simply  the  depression  or  the  irritability  which  frequently 
goes  with  pregnancy  until  some  insane  act  suddenly  opens  the  eyes  of 
the  obstetrician  and  the  family. 

It  is  most  often  found  associated  with  some  form  of  toxemia  and  this 
possibility  should  always  be  borne  in  mind  when  considering  the  treat- 
ment of  the  condition. 

Relative  Frequency. — Alienists  in  charge  of  asylums  usually  assign  to 
maternity  and  its  associated  conditions  about  15  per  cent,  of  the  cases  of 
insanity  among  their  female  patients.  Abt  divides  this  percentage  as  follows : 

Insanity  of  pregnancy,  2  per  cent. 

Insanity  of  the  puerperium,  9  per  cent. 

Insanity  of  lactation,  4  per  cent. 

Varieties. — Insanity  complicating  pregnancy  may  present  one  of  two 
general  types:    (1)  A  melancholia.    (2)  A  mania. 

Melancholia. — The  mental  depression  experienced  at  times  by  a  great 
many  pregnant  women  otherwise  normal  may  be  exaggerated  to  such 


DISEASES  OF   THE  NERVOUS  SYSTEM  457 

a  degree  as  to  amount  to  a  typical  melancholia  with  perhaps  suicidal 
tendencies.  It  may  assume  a  religious  phase  and  the  patient  be  over- 
whelmed with  her  sense  of  sin  and  unworthiness. 

Mania. — On  the  other  hand  the  mind  of  the  patient  may  be  in  a  state 
of  intense  activity  and  excitement  with  occasional  violent  outbreaks. 
Varied  hallucinations  may  be  present  and  in  her  periods  of  excitement 
and  violence  she  may  injure  herself  or  those  about  her.  In  the  author's 
experience  melancholia  during  pregnancy  has  been  much  more  common 
than  mania. 

Diagnosis. — ^The  dividing  line  between  the  natural  psychoses  of  preg- 
nancy and  insanity  is  often  difficult  to  fix,  especially  is  this  true  in  patients 
who  are  anxious  to  have  their  pregnancy  interrupted  and  for  that  reason 
are  willing  to  appear  mentally  unsound.  The  only  safe  course  for  the 
obstetrician  in  these  circumstances  is  to  share  the  responsibility  and 
associate  with  himself  an  alienist,  that  they  together  may  observe  the 
case  and  decide  upon  the  treatment. 

Treatment. — ^The  first  step  in  the  treatment  of  the  insanity  of  preg- 
nancy is  to  safeguard  the  patient  against  injuring  herself  or  others. 
She  should  not  be  left  alone  for  a  moment  night  or  day,  and  for  this 
reason  two  nurses  are  needed,  sometimes  even  four.  Considering  the 
fact  that  quite  a  large  percentage  of  the  cases  are  of  toxemic  origin  the 
bowels  should  be  freely  moved,  the  diet  should  be  carefully  regulated 
to  meet  the  needs  of  the  individual  and  elimination  favored  by  large 
draughts  of  water,  etc.  If  the  patient  is  poorly  nourished  her  nutrition 
should  be  increased  if  possible,  and  if  she  refuses  to  eat  nourishment  should 
be  introduced,  by  moral  suasion  if  possible,  otherwise  by  the  stomach- 
tube.  She  should  be  given  sleep  and  for  this  purpose  the  milder  hypnotics 
like  the  bromides,  chloral,  veronal,  etc.,  may  be  tried  first,  but  where 
the  patient  is  very  excitable  the  author  has  succeeded  best  with  hyoscin 
hydrobromate,  gr.  ywo  ^-  4  h.,  supplemented  if  necessary  with  a  hypo- 
dermic injection  of  morphin. 

The  question  of  induction  of  labor  naturally  presents  itself.  As  a  rule 
the  insanity  of  pregnancy  usually  disappears  spontaneously  shortly  after 
delivery.  For  this  reason,  if  under  treatment  for  toxemia  and  with 
nerve  sedatives  the  mental  condition  does  not  clear  and  especially  if 
true  suicidal  tendencies  develop,  in  the  opinion  of  the  author  the  uterus 
should  be  emptied. 

Asylum  Treatment. — ^For  insanity  complicating  pregnancy  the  stigma 
resting  upon  one  committed  to  an  institution  is  so  great  that  it  is 
desirable,  if  the  patient  can  be  properly  nursed  at  home  or  in  a  general 
hospital,  not  to  commit  her  to  an  asylum  unless  the  interruption  of 
pregnancy  has  failed  to  restore  the  mental  balance. 

Puerperal  Insanity. — This  may  appear  as  a  continuation  and  exag- 
geration of  the  psychoses  manifest  during  the  pregnancy,  or  may  develop 
suddenly  at  any  time  during  the  puerperium,  i.  e.,  durmg  the  first  month 
following  the  delivery.  It  may  seem  to  develop  with  the  agony  of  a 
severe  second  stage  of  labor  and  continue  into  the  puerperium,  but  in 
the  author's  experience  it  has  developed  most  often  in  the  second  week 


458       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

of  the  puerperium.  In  addition  to  this  period  of  development  a  certain 
number  of  cases  seem  to  arise  after  the  puerperium  proper  in  women 
overtaxed  by  the  drain  upon  the  system  from  nursinji;  their  child;  this 
form  bein<j  called  insanity  of  Uiciation. 

Etiology. — As  in  insanity  complicatino;  pregnancy,  puerperal  insanity 
may  arise  as  the  result  of  a  toxemia,  and  not  a  few  cases,  subjects  of  an 
eclamptic  seizure,  have  to  pass  through  a  period  of  puerperal  insanity. 
Moreover,  puerperal  insanity  in  a  considerable  })roportion  of  cases  is  so 
closely  related  to  an  infection  that  puerperal  infection  must  be  looked 
upon  as  an  important  factor  in  the  etiology.  Sudden  grief  or  mental 
shock,  as  the  loss  of  the  child  in  a  person  with  delicate  mental  balance, 
not  infrequently  serves  as  an  inciting  cause. 

The  same  varieties  of  insanity,  /.  e.,  melancholia  and  mania,  are  present 
in  puerperal  insanity  as  are  seen  in  that  complicating  pregnancy.  In 
the  insanity  of  lactation  the  melancholic  type  is  more  common  than 
mania. 

Prognosis. — The  insanity  associated  with  maternity,  whether  it  be  that 
of  pregnancy,  the  puerperium,  or  lactation,  usually  has  a  good  prognosis, 
and  it  may  be  said  that  the  more  acute  the  onset  and  the  more  violent 
the  symptoms  the  better  the  prognosis.  As  a  rule  the  patient  recovers 
in  from  two  weeks  to  six  months,  but  although  some  patients  will  pass 
through  a  subsequent  pregnancy  without  mental  disturbance,  it  must 
be  borne  in  mind  that  there  is  always  a  tendency  to  recurrence  with  the 
repetition  of  the  pregnancy. 

As  already  stated,  the  prognosis  of  insanity  associated  with  maternity 
is  usually  good,  yet  the  author  will  never  forget  the  impression  made 
upon  him  when  called  to  an  institution  for  the  insane  to  operate  for 
hemorrhoids  upon  an  inmate  who,  a  brilliant  young  woman,  in  her  first 
confinement  twent}'  years  ago  had  been  afflicted  with  insanity  from  which 
she  had  never  recovered. 

Treatment. — The  same  safeguarding  of  the  patient  by  constant  attend- 
ance as  recommended  in  the  treatment  of  the  insanity  of  pregnancy  is 
imperative  here  and  even  more  so,  as  another  factor — the  child — has 
entered  the  problem,  and  the  danger  of  the  mother  in  an  unguarded 
moment  doing  injury  to  her  child  is  so  great  that,  as  a  rule,  the  child  should 
be  taken  from  the  breast  and  not  allowed  to  nurse.  In  a  few  cases  the 
secretion  of  the  milk  may  be  maintained  by  expression  or  by  drawing  it 
off  with  a  breast-pump  in  the  hope  that  the  mental  aberration  will  be  of 
very  short  duration  and  that  the  baby  may  then  be  returned  to  the  breast. 
The  same  methods  of  securing  sleep  and  maintaining  nutrition  may  be 
followed  here  as  in  treating  the  insanity  of  pregnancy.  In  the  insanity 
of  the  puerperium  the  difficulty  and  the  expense  of  maintaining  for  a 
sufficient  time  in  her  own  home  the  proper  safeguards  and  nursing  of 
the  patient  and  the  child  make  resort  to  commitment  to  an  asylum  more 
often  advisable  or  necessary.  In  the  insanity  of  lactation  the  cessation 
of  nursing,  the  general  upbuilding  of  the  mother,  both  nervously  and 
physically,  and  the  safeguarding  of  both  mother  and  child  are  the  prin- 
ciples of  treatment  to  be  observed. 


CARDIAC  DISEASE  IN  PREGNANCY  459 

Epilepsy. — One  of  the  important  questions  of  the  day  is  that  of  eugenic 
marriages,  and  efforts  are  wisely  being  made  to  prevent  the  marriage  of 
the  unfit. 

Certain  it  is  that  children  should  not  be  brought  into  the  world  by 
epileptic  parents.  These  children  are  usually  feeble,  poorly  nourished 
and  frequently  die  of  congenital  epilepsy.  Fortunately  epileptics  are 
frequently  sterile,  so  that  congenital  epilepsy  is  rare.  As  a  rule  epilepsy 
has  very  little  effect  on  pregnancy  and  during  it  convulsions  are  rather 
less  frequent  than  usual.  During  the  puerperium,  however,  there  seems 
to  be  a  tendency  to  an  increased  frequency.  An  epileptic  seizure  is  often 
confused  with  eclampsia  but  the  absence  of  urinary  changes  and  the  his- 
tory of  previous  attacks  usually  enables  the  diagnosis  to  be  made. 

Treatment. — Epilepsy  during  pregnancy  and  the  puerperium  should 
be  treated  as  in  the  non-pregnant  state.  Careful  diet,  attention  to 
elimination  by  the  bowels  and  the  bromides  generally  serve  the  purpose. 
On  account  of  the  risk  of  the  mother  injuring  the  baby  during  an  epileptic 
seizure  and  because  the  drain  of  the  nursing  and  the  stimulation  of  the 
breasts  seem  to  favor  an  increase  in  the  number  of  epileptic  seizures,  it 
is  usually  unwise  to  allow  an  epileptic  mother  to  nurse  her  child. 

Hemiplegia. — On  account  of  the  frequency  of  toxemia  in  pregnancy 
and  the  tendency  to  hemorrhages  in  toxemia  a  cerebral  hemorrhage  with 
a  resulting  hemiplegia  is  not  a  very  rare  complication  of  pregnancy  and 
the  puerperium. 

Although  the  prognosis  depends  upon  the  size  and  location  of  the 
hemorrhage,  as  a  rule  it  is  good  and  the  woman  rapidly  regains  power 
after  delivery.  The  hemiplegia  has  little  effect  upon  the  labor  itself. 
Thrombophlebitis,  one  of  the  common  results  of  puerperal  infection, 
and  occasionally  complicating  pregnancy,  may  give  rise  to  a  cerebral 
embolus  with  various  paralyses,  depending  upon  the  area  from  which  the 
circulation  is  excluded. 

Paraplegia. — Paraplegia  is  a  rare  complication  of  pregnancy,  being 
usually  due  to  a  spinal  lesion  independent  of  the  pregnant  state.  A 
few  cases  have  been  reported  as  being  associated  with  a  toxemia.  The 
labor  in  cases  of  paraplegia  is  usually  normal  and  accompanied  by  less 
pain  than  usual. 

DISEASES    OF   THE   BONES   AND   JOINTS. 

These  will  be  discussed  under  the  head  of  deformities  of  the  pelvis 
resulting  therefrom  (see  p.  665). 

CARDIAC   DISEASE   IN   PREGNANCY. 

The  condition  and  behavior  of  the  normal  heart  in  pregnancy  has 
already  been  discussed  under  the  Physiology  of  Pregnancy  (see  page  134) . 
Chronic  cardiac  disease  with  resulting  valvular  lesions  is  associated  with 
pregnancy  in  a  certain  proportion  of  cases.  According  to  Fellner  and 
Vinay  the  frequency  of  this  association  is  about  2  per  cent. 


460       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

Occasionally  hearts  which  in  the  non-pregnant  state  present  no  abnor- 
mal sounds,  gi\e  distinct  murmurs  in  the  latter  part  of  pregnancy, 
showing  that  valves  which  may  be  competent  for  the  ordinary  demands 
upon  the  heart  are  not  equal  to  the  increased  demand  of  pregnancy. 
The  usual  lesion  is  chronic  endocarditis,  existing  prior  to  pregnancy, 
although  the  pregnancy  may  be  the  cause  of  an  exacerbation  of  it,  and 
rarely  an  acute  endocarditis  may  arise  during  the  pregnancy.  Less  com- 
mon lesions  of  the  heart  complicating  pregnancy  and  the  puerperium, 
especially  the  latter,  are  myocarditis  and  fatty  degeneration.  The 
myocarditis  is  most  often  the  result  of  puerperal  infection,  while  the 
fatty  degeneration  may  follow  a  severe  toxemia  or  be  the  result  of  a 
prolonged  chloroform  anesthesia. 

The  mitral  lesions  are  much  more  frequent  than  the  aortic  and  for- 
tunately mitral  insufficiency  is  much  more  frequent  than  mitral  stenosis. 

Prognosis. — Of  all  the  complications  of  pregnancy  there  is  none  in  which 
the  prognosis  is  more  uncertain  than  a  serious  cardiac  lesion,  especially 
a  mitral  stenosis.  Young,  otherwise  healthy  women,  with  a  mitral 
insufficiency  well  compensated,  will,  judging  from  the  author's  experience, 
usually  pass  through  pregnancy  and  the  puerperium  with  very  little  if 
any  trouble.  With  a  mitral  stenosis  the  prognosis  is  much  more  grave, 
but  in  all  cardiac  diseases  complicating  pregnancy  the  prognosis  depends 
largely  upon  whether  any  lack  of  compensation  has  existed  prior  to  the 
pregnancy. 

If  compensation  has  failed  in  the  non-pregnant  state,  this  failure 
is  very  apt  to  recur  and  increase  during  pregnancy,  when  the  demands 
upon  the  heart  are  so  much  greater.  This  is  especially  true  in  the  case 
of  a  mitral  stenosis.  Moreover,  while  a  diseased  heart  may  pass  safely 
through  a  normal  pregnancy  and  labor,  it  is  poorly  fitted  to  endure  the 
common  complications  of  either,  as  a  toxemia,  a  long  tedious  labor, 
a  severe  hemorrhage  or  infection.  Moreover,  the  heart  which  tends  to 
lose  compensation  in  a  normal  single  pregnancy  and  labor  has  this  ten- 
dency exaggerated  if  the  pregnancy  is  multiple.  Again,  a  patient  suffer- 
ing with  an  endocarditis  may  pass  safely  through  her  pregnancy  and  per- 
haps her  labor  and  then  suddenly  die  of  a  pulmonary  or  cerebral  embolism. 

According  to  Fellner,  in  about  20  per  cent,  of  cases  of  serious  cardiac 
lesion,  abortion  or  premature  labor  results.  This  may  be  caused  by 
accidental  hemorrhage,  by  placental  changes,  or  by  the  death  of  the  fetus 
from  insufficient  oxidation  of  the  fetal  blood. 

Treatment. — ]Much  depends  upon  the  care  of  the  patient  during  her 
pregnancy,  and  if  she  is  willing  to  cooperate  with  her  obstetrician,  many 
cases  may  be  carried  safely  through  maternity  which  otherwise  would 
be  lost.    The  following  are  the  chief  principles  of  treatment: 

1.  Relieve  the  work  of  the  heart  as  much  as  possible. 

2.  Watch  for  lack  of  compensation. 

3.  Use  cardiac  tonics,  as  digitalis,  when  indicated. 

4.  In  a  few  cases  interrupt  the  pregnancy. 

Relief  of  Cardiac  Work. — This  implies  the  avoidance  of  all  violent  exer- 
cise durmg  pregnancy,  the  relief  of  pelvic  pressure  by  careful  attention 


CARDIAC  DISEASE  IN  PREGNANCY  461 

to  the  bowels,  and  the  proper  support  of  the  abdomen  and  enlarging 
uterus.  The  amount  of  rest  required  by  the  patient  depends  largely  upon 
the  gravity  of  the  lesion  and  the  completeness  of  the  compensation.  The 
author  has  succeeded  in  carrying  some  patients  with  marked  mitral 
stenosis  safely  through  pregnancy  and  labor,  even  after  symptoms  of 
lack  of  compensation,  by  keeping  them  extremely  quiet  during  most  of 
the  pregnancy,  having  them  spend  a  large  part  of  their  time  in  bed, 
varjang  the  monotony  by  moving  them  in  a  wheel-chair  to  a  porch  for 
fresh  air  and  diversion  and  then  to  a  couch  or  reclining  chair  for  the 
remainder  of  the  day.  When  the  time  of  labor  has  arrived,  in  order  to 
relieve  the  work  of  the  heart  as  much  as  possible,  violent  muscular  strain, 
such  as  the  powerful  expulsive  efforts  of  the  second  stage,  should  be 
avoided  by  the  employment  of  ether  anesthesia  and  the  early  use  of  the 
forceps,  or  by  breech  extraction  if  the  presentation  is  that  of  a  breech. 

Watch  for  Lack  of  Compensation. — This  is  usually  evidenced  by  irregu- 
larity and  increased  frequency  of  the  pulse,  by  cyanosis  of  the  lips  and 
fingers,  by  pulmonary  congestion  and  edema  with  dyspnea,  perhaps  with 
a  hacking  cough.  The  patient  is  often  restless,  cannot  sleep  lying  down, 
and  digestion  is  often  impaired.  These  symptoms  and  signs  should  always 
be  watched  for,  and  to  a  certain  extent  anticipated  by  treatment. 

The  Use  of  Cardiac  Tonics. — The  drug  which  usually  serves  best  to 
prevent  lack  of  compensation  and  to  deal  with  it  when  present  is  digitalis. 
Strychnin  is  also  valuable,  but  the  use  of  digitalis  in  small  doses  for 
several  weeks  at  a  time,  and  then  repeated  after  an  interval  of  one  to 
three  weeks  in  cases  threatened  with  failing  compensation,  usually  works 
well. 

During  labor,  when  the  strain  upon  the  heart  is  great  and  when  collapse 
is  threatened,  some  rapidly  acting  cardiac  stimulant  should  be  given. 
The  delivery  of  a  patient  suffering  with  a  severe  cardiac  lesion  should 
be  surrounded  with  every  safeguard  for  dealing  with  sudden  cardiac 
failure  or  pulmonary  congestion :  the  usual  cardiac  tonics,  oxygen,  plenty 
of  assistants  to  watch  the  case,  etc. 

For  the  dyspnea  and  restlessness  often  associated  with  cardiac  disease, 
codein  or  small  doses  of  morphin  may  be  used  with  advantage. 

Interru'ption  of  Pregnancy. — If  a  woman  with  a  poorly  compensated 
heart  contemplates  marriage  she  should  have  explained  to  her  and  her 
fiance  the  danger  of  pregnancy  in  her  condition. 

The  question  of  interruption  of  pregnancy  depends  chiefly  on  that  of 
compensation  of  the  heart.  If  compensation  is  good  and  the  patient 
is  willing  to  be  careful  and  obey  orders,  interruption  of  the  pregnancy  is 
unnecessary.  On  the  other  hand,  if  the  patient  shows  increasing  failure 
of  compensation,  interruption  of  the  pregnancy  may  be  the  only  proced- 
ure which  will  save  her  life.  The  time  of  this  interruption  may  not  be 
an  easy  problem  to  solve. 

If  compensation  fails  early  in  pregnancy  the  decision  is  usually  easy, 
and  emptying  the  uterus  with  the  least  shock  to  the  patient,  usually 
with  a  preliminary  gauze  packing  of  cervical  canal  and  vagina  for  twelve 
to  twenty-four  hours,  is  the  procedure  indicated.    If  the  period  of  gesta- 


462       AFFECTIOXS  AND  DISEASES  COMPLICATIXG  PREGNANCY 

tion  is  about  six  months,  and  the  cervix  is  long  and  rigid,  the  difficulty 
of  emptying  the  uterus  at  this  period  is  sometimes  so  great  that  it  is 
wiser  to  wait  until  a  little  later  when  there  is  a  chance  of  saving  the 
child  and  the  cervix  is  shorter  and  softer. 

PULMONARY   AFFECTIONS    COMPLICATING   PREGNANCY. 

Dyspnea. — The  difficulty  in  breathing  often  experienced  in  pregnancy 
may  be  of  two  varieties — mechanical  or  neurotic. 

Mechanical. — In  the  latter  months  of  pregnancy,  as  the  uterus  enlarges 
and  occupies  a  large  part  of  the  abdomen,  the  descent  of  the  diaphragm 
and  therefore  the  expansion  of  the  lungs  is  interfered  with  and  on  exercise, 
such  as  going  up  stairs,  hill  climbing,  etc.,  the  patient  experiences  more 
or  less  dyspnea. 

In  a  normal  single  pregnancy  this  usually  is  of  little  consequence,  but 
in  cases  where  the  abdominal  distention  is  unusually  great,  as  in  mul- 
tiple pregnancy,  hydramnios,  pregnancy  associated  with  a  tumor,  etc., 
the  dyspnea  may  be  very  annoying,  requiring  the  patient  to  sleep  with 
several  pillows. 

Neurotic  or  Spasmodic. — Occasionally  in  pregnancy,  especially  in  neu- 
rotic individuals,  there  occurs  a  form  of  dyspnea,  which  from  its  evanes- 
cent character  and  the  absence  of  any  lesion  to  be  detected  between  the 
attacks  is  usually  called  neurotic,  spasmodic  dyspnea,  and  is  best  treated 
by  nerve  sedatives. 

Before  diagnosing  a  dyspnea  of  pregnancy  neurotic,  however,  care  must 
be  taken  not  to  overlook  a  toxemia  which  with  its  accompanying  contrac- 
tion of  the  arterioles  may  be  the  cause  of  the  dyspnea.  In  other  words, 
no  dyspnea  should  be  called  neurotic  unless  lesions  of  the  kidneys,  heart, 
etc.,  can  be  excluded. 

Emphysema. — Patients  suffering  with  emphysema  prior  to  pregnancy 
usually  have  their  symptoms  much  exaggerated  by  pregnancy.  This 
exaggeration  may  arise  both  from  the  mechanical  interference  with  the 
normal  action  of  the  diaphragm  and  from  the  neurotic  tendencies  which 
pregnancy  so  often  brings  out. 

Emphysema  from  interference  with  the  normal  oxygenation  of  the  fetal 
blood  and  the  resulting  accumulation  of  carbon  dioxide  occasionally 
stimulates  the  uterus  to  contract  and  causes  a  premature  expulsion  of  the 
ovum  or  fetus.  On  the  other  hand,  the  symptoms  sometimes  become  so 
distressing  that  in  the  interest  of  the  mother  it  is  necessary  to  interrupt 
the  pregnancy. 

Asthma. — Women  who  are  subject  to  asthmatic  attacks  are  very 
likely  to  have  these  attacks  increased  in  frequency  and  severity  when 
they  become  pregnant.  ]\I()re()ver,  some  women  will  suffer  from  asthma 
during  pregnancy  who  have  never  before  been  troubled  with  it.  This 
variety  seems  to  be  due  to  the  pregnancy  itself  and  usually  persists  more 
or  less  until  delivery  when,  as  a  rule,  it  disappears.  The  treatment  of 
asthma  complicating  pregnancy  is  the  same  as  that  in  the  non-pregnant 
state.     Change  to  a  clear,  dry  atmosphere  usually  gives  the  patient  relief. 


PULMONARY  AFFECTIONS  COMPLICATING  PREGNANCY     463 

Reflex  Cough  of  Pregnancy. — Some  women  without  demonstrable 
lesions  of  the  throat  or  respiratory  tract  will  suffer  with  an  irritable 
cough  which  is  annoying  and  very  persistent,  in  spite  of  the  usual 
methods  of  treatment.  Spraying  the  throat  with  astringent  lotions  will 
sometimes  give  relief,  but  in  many  cases  it  resists  all  treatment  but 
disappears  rapidly  after  delivery. 

Hemoptysis. — Hemorrhage  from  the  respiratory  tract  occasionally 
occurs  during  pregnancy  without  demonstrable  lesions  or  subsequent 
lung  involvement.  It  often  seems  associated  with  an  overacting  heart 
in  neurotic  women  and  sometimes  seems  to  be  of  the  nature  of  a  vicarious 
menstruation.  In  the  absence  of  pulmonary  lesion  no  treatment  is 
required  save  reassurance,  rest,  and  nerve  sedatives. 

Tuberculosis  Complicating  Pregnancy. — This  question  may  well  be 
studied  under  two  heads:  (1)  The  effect  of  pregnancy  upon  tuberculosis. 
(2)  The  eft'ect  of  tuberculosis  upon  pregnancy. 

The  Effect  of  Pregnancy  upon  Tuberculosis. — Varying  with  the  site  and 
type  of  the  tuberculous  lesion  present,  most  observers  are  agreed  that  the 
effect  of  pregnancy  upon  tuberculosis  is  a  deleterious  one.  This  harmful 
effect  is  least  pronounced  in  the  chronic  process  called  "fibroid  phthisis." 
It  is  most  pronounced  in  tuberculosis  of  the  larynx.  Patients  with 
latent  tuberculosis  in  the  sense  of  having  in  certain  lymphatic  glands  of 
the  body  tuberculous  foci  which  have  for  years  remained  localized,  may, 
with  the  occurrence  of  pregnancy,  have  this  tuberculous  process  extend  to 
the  lungs  and  even  become  general.  Patients,  moreover,  with  an  arrested 
pulmonary  tuberculosis  not  infrequently  have,  with  the  occurrence  of 
pregnancy,  a  lighting  up  of  this  process  with  an  active  extension  as  the 
pregnancy  advances.  Again,  a  tuberculous  pregnant  woman,  especially 
one  with  a  fibroid  phthisis,  may  pass  through  pregnancy  with  apparently 
little  exacerbation  of  her  tuberculous  process,  and  then  in  her  puerperium, 
perhaps  as  a  result  of  the  strain  of  the  labor  and  the  anesthetic,  develop 
a  rapid  extension  of  the  disease,  perhaps  causing  her  death  in  a  short 
time  from  an  acute  general  tuberculosis. 

The  reason  for  the  deleterious  effect  of  pregnancy  upon  tuberculosis 
seems  clearly  to  be  the  reduced  vitality  of  the  woman  resulting  from 
the  increased  demand  of  pregnancy  upon  her  blood,  the  increased 
tax  upon  her  different  organs,  and  the  drain  upon  her  system,  resulting 
from  the  different  complications  of  pregnancy  and  labor  as  toxemia, 
especially  that  form  characterized  by  hyperemesis,  hemorrhage,  infection, 
etc.  In  a  few  cases,  especially  in  those  suffering  with  fibroid  phthisis, 
the  tuberculous  patient  seems  for  a  time  to  improve  during  the  pregnancy. 
This  may  be  due  to  the  increased  nutrition  often  seen  in  normal  pregnancy, 
or  in  exceptional  cases  to  an  increased  expansion  of  the  upper  portions 
of  the  lung;  the  lower  portions  being  compressed  by  the  upward  pressure 
of  the  enlarging  uterus  upon  the  diaphragm. 

That  a  tuberculous  woman,  however,  should  have  her  tuberculosis 
improved  by  pregnancy  is  not  a  result  to  be  counted  upon  or  expected. 

The  Effect  of  Tuberculosis  upon  Pregnancy. — The  association  of  preg- 
nancy with  tuberculosis  is  so  commonly  seen  that  any  tendency  of  the 


464     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

disease  to  cause  sterility,  which  by  some  is  supposed  to  exist,  must  be 
a  very  slight  one.  Nor  does  the  disease  commonly  cause  an  interruption 
of  pregnancy.  In  a  few  advanced  cases,  however,  on  account  of  insuffi- 
cient oxygenation,  or  on  account  of  a  tuberculous  change  in  the  placenta, 
premature  labor  occurs. 

As  a  rule  tuberculous  women  have  poorly  nourished,  feeble  children, 
born  with  what  might  be  called  a  tuberculous  tendency  or  a  soil  suitable 
for  the  growth  of  the  tubercle  bacillus.  On  the  other  hand  the  author 
has  occasionally  delivered  tuberculous  women  of  large,  healthy-looking 
babies  who  apparently  had  every  prospect  of  future  well-being. 

A  sufficient  number  of  cases  are  now  on  record  to  demonstrate  that 
tuberculosis  may  at  times  be  transplanted  directly  from  mother  to  fetus. 

Birch-Hirschfeld,^  in  1891,  demonstrated  tuberculosis  in  the  fetus 
itself.  Sitzenfrey,^  in  1909,  was  able  to  demonstrate  tubercle  bacilli  in 
the  blood  of  two  children  in  a  series  of  twenty-six  born  of  tuberculous 
women. 

Through  the  investigation  of  Schmol,  Novak  and  others,  the  tuber- 
culosis of  the  placenta  has  been  shown  to  be  a  common  lesion  in  tuber- 
culous women ;  the  frequency  varying  in  different  series  of  cases  from  50 
to  70  per  cent. 

Friedman,^  by  experiments  on  animals,  was  able  to  demonstrate  the 
possibility  of  fetal  tuberculosis  by  the  introduction  of  tubercle  bacilli 
along  with  the  spermatozoa.  The  possibility  of  congenital  tuberculosis 
in  the  human  fetus  must  therefore  be  considered  established  and  yet 
in  spite  of  a  not  infrequent  involvement  of  the  placenta  in  tuberculous 
women,  the  birth  of  healthy  children  is  so  common  that  congenital  tuber- 
culosis must  be  considered  the  exception  rather  than  the  rule.  It  is 
easy  to  understand  that  a  child  born  with  a  soil  suitable  for  the  growth 
of  tubercle  bacilli  and  living  with  one  or  more  tuberculous  parents  easily 
becomes  infected,  even  if  it  did  not  have  congenital  tuberculosis. 

Treatment. — The  desirability  of  eugenic  marriages  in  the  interest 
both  of  the  family  and  the  State  is  so  well  established  at  present  that 
there  can  be  no  question  as  to  the  advice  to  be  given  to  a  patient  in  active 
tuberculosis.  For  her  own  sake,  for  the  sake  of  her  husband-to-be,  and 
for  the  sake  of  her  possible  child  or  children,  she  should  not  marry. 
Her  chances  of  recovery  would  be  lessened  by  a  pregnancy.  She  is  likely 
to  infect  her  husband;  she  is  likely  to  infect  her  child  either  before  or  after 
birth. 

If  a  candidate  for  matrimony  has  a  healed  tuberculosis  she  may  consult 
neither  her  physician  nor  an  obstetrician  as  to  the  wisdom  of  marriage, 
but  if  opportunity  arises  she  should  be  advised  of  the  danger  of  maternity 
in  her  condition  and  that  there  is  a  possibility  that  her  tuberculous 
process,  now  quiescent  and  local,  may  be  rendered  active  and  general 
by  a  pregnancy. 

1  Arbeiten  d.  Pathol.  Inst,  zu  Leipzig,  Jena,  1891,  p.  428. 

2  Die  Lehre  von  den  Kongenitalen  Tuberculose,  etc.,  Berlin,  1909,  clxxxi,  150-179. 

3  Exp.  Beitrage  z.  Frage  Kongenitaler  Tuberkelbazillen  iibertragung,  etc.,  Virchow's 
Archiv,  1905. 


PULMONARY  AFFECTIONS  COMPLICATING  PREGNANCY     465 

The  problem  often  confronting  the  obstetrician  is  what  advice  should 
be  given  to  a  tuberculous  pregnant  woman?  This  depends  a  good  deal 
upon  the  state  of  the  tuberculosis  and  the  period  of  pregnancy,  especially 
the  former. 

In  the  first  place  the  author  believes  firmly  that  a  woman  in  the  early 
months  of  pregnancy,  in  active  tuberculosis,  with  temperature,  cough, 
etc.,  should  have  her  pregnancy  interrupted  whether  the  tuberculosis  is 
laryngeal  or  pulmonary.  She  needs  every  ounce  of  her  vitality  to  com- 
bat her  tuberculosis.  A  continuance  of  her  pregnancy  is  almost  certain 
to  stimulate  the  development  and  spread  of  the  tuberculous  process;  to 
lower  her  vitality  and  greatly  lessen  her  chances  of  recovery.  Even  if 
the  patient  seems  to  be  enduring  her  pregnancy  with  slight  exacerbation 
of  her  tuberculous  symptoms,  so  many  women  thus  afflicted  go  down 
rapidly  after  confinement  that  the  position  taken  above  seems  justified. 

With  regard  to  laryngeal  tuberculosis,  this  procedure  has  received 
general  endorsement,  and  the  plan  of  emptying  the  uterus  in  the  early 
months  of  every  pregnancy  complicated  by  an  active  tuberculosis  is 
rapidly  gaining  ground.  Trembley,  of  Saranac  Lake,  so  intimately 
associated  with  tuberculosis,  shares  this  view.  The  obstetrician  should 
be  prepared  at  all  times  for  an  emergency  tracheotomy  with  patients 
suffering  with  a  laryngeal  tuberculosis.  If  the  patient  with  active  tuber- 
culosis first  presents  herself  to  the  obstetrician  in  the  latter  months  of 
pregnancy  the  course  to  be  followed  must  be  determined  by  the  conditions 
in  the  individual  case.  If  the  tuberculosis  seems  to  be  increasing  and  the 
patient  losing  ground  the  pregnancy  should  be  interrupted  on  the  ground 
that  in  pregnancy  the  life  and  future  health  of  the  mother  should  take 
precedence  over  that  of  the  child.  Moreover,  if  the  period  of  viability 
of  the  child  has  been  reached  the  interruption  of  the  pregnancy  may 
even  be  to  its  advantage,  rather  than  to  allow  it  to  go  to  term  with  the 
risk  of  its  becoming  infected  from  the  placenta.  If  the  child  has  not 
yet  reached  its  period  of  viability,  but  is  near  it,  it  may  be  advisable  to 
postpone  for  a  time  the  induction  of  the  labor,  meanwhile,  by  fresh 
air  and  other  hygienic  measures  endeavoring  to  improve  the  general 
condition  of  the  mother. 

If  the  woman  is  in  the  last  stages  of  a  tuberculosis  it  is  a  debatable 
question  whether  to  empty  the  uterus  or  not,  as  the  mere  procedure  of 
the  interruption  may  hasten  the  departure  of  the  woman  and  the  decision 
must  be  determined  largely  by  the  conditions  present  in  the  individual 
case,  the  strength  of  the  mother,  and  the  development  of  the  child. 

When  the  patient  presents  herself  pregnant,  but  with  an  arrested 
tuberculosis,  the  problem  is  a  different  one.  If  the  arrest  has  been  a 
recent  one  and  the  pregnancy  is  in  its  early  stages  the  author  believes 
that  it  should  be  interrupted.  If,  on  the  other  hand,  the  tuberculous 
process  has  been  arrested  for  years  and  the  patient  is  willing  to  surround 
her  life  with  all  safeguards  such  as  proper  climate,  sleeping  out  of  doors, 
etc.,  the  continuance  of  the  pregnancy  may  be  allowed  under  careful 
supervision.  At  the  time  of  her  labor,  effort  should  be  made  to  save  her 
strength  as  much  as  possible,  to  use  as  little  anesthesia  as  possible,  an4 
30 


466       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

to  avoid  any  unnecessary  blood  loss.  She  should  be  informed  of  the 
danger  of  frequent  repetition  of  pregnancy  and  should  be  advised  against 
it.  She  should  in  the  interests  of  both  herself  and  her  child  not  be  allowed 
to  nurse. 

If  emptying  of  the  uterus  is  indicated  in  the  early  months,  as  in  a 
pregnancy  complicated  by  an  active  tuberculosis,  the  procedure  here, 
as  at  term,  should  be  carried  out  with  the  least  shock  to  the  woman 
and  the  least  anesthesia  possible.  The  best  plan,  after  two  months  of 
gestation,  is  usually  to  perform  the  operation  in  two  stages,  first  packing 
the  cervical  canal  and  vagina  firmly  with  bismuth  gauze  or  a  weak 
iodoform  gauze,  and  then  at  the  end  of  twelve  to  twenty-four  hours,  after 
the  cervix  has  become  softened  and  dilated,  emptying  the  uterus  with 
the  sterile,  gloved  finger,  curette,  and  looped  sponge  holder. 

One  phase  of  the  tuberculous  woman's  condition  after  confinement 
deserves  mention.  I'sually  her  chart  will  show  a  temperature  which 
is  naturally  regarded  as  tuberculous  and  yet  the  possibility  of  a  sapremia 
in  a  tuberculous  woman  must  not  be  overlooked.  Not  infrequently  the 
tone  of  her  uterus  is  below  normal  and  blood-clots  and  lochia  are  often 
retained  Avith  putrefactive  changes.  In  a  number  of  cases  seen  by  the 
author  the  temperature  of  a  tuberculous  woman  in  the  puerperium 
came  to  normal  after  a  gentle  intra-uterine  douche  had  washed  away 
decomposing  organic  material. 

Pneumonia  Complicating  Pregnancy. — Pneumonia  during  pregnancy 
is  a  serious  complication  viewed  from  the  standpoint  of  either  the  pneu- 
monia or  the  pregnancy,  as  each  handicaps  the  other.  The  mechanical 
interference  with  full  lung  expansion  in  pregnancy,  especially  during  the 
later  months,  greatly  adds  to  the  dyspnea  of  the  pneumonia  and  the 
consolidation  of  a  portion  of  one  or  both  lungs  interferes  with  the  normal 
oxygenation  of  both  mother  and  fetus.  Interruption  of  the  pregnancy  is 
a  common  result  of  this  insufficient  oxygenation  as  well  as  of  the  infec- 
tion itself,  with  its  high  temperature,  death  of  the  fetus,  etc.  A  number 
of  cases  are  on  record  by  Carbonelli,  Netter  and  others  in  which  pneu- 
mococci  were  found  in  the  fetal  organs.  The  frequency  of  this  interrup- 
tion of  the  pregnancy  increases  as  the  pregnancy  approaches  term,  thus, 
as  generally  considered,  pneumonia  interrupts  the  pregnancy  in  about  40 
per  cent,  of  the  cases  during  the  first  half  and  in  about  60  per  cent,  during 
the  second  half.  According  to  Vinay  about  60  per  cent,  of  these  prema- 
ture children  die  from  the  prematurity  and  the  pneumococcus  infection. 

The  maternal  mortality  of  pneumonia  in  pregnancy  is  high.  In  Ricau's^ 
series  of  43  cases,  12  died;  a  mortality  of  28  per  cent. 

Pneumonia  Complicating  the  Puerperium. — This  may  be  due  to  several 
causes:  It  may  be  the  result  of  the  anesthetic  used  during  the  delivery; 
it  may  be  the  continuance  of  a  pneumococcus  infection  from  jjregnancy 
into  the  puerperium;  it  may  arise  as  a  fresh  pneuuKX-occus  infection 
during  the  puerperium,  or  it  may  complicate  a  puerperal  infection  either 
as  a  result  of  a  septic  embolus  or  as  a  hypostatic  congestion  from  enfeebled 

1  Th^se  de  Paris.  1874. 


PULMONARY  AFFECTIONS  COMPLICATING  PREGNANCY     467 

circulation.  The  mortality  of  pneumonia  in  the  puerperium  is  greater 
than  of  that  occurring  during  the  pregnancy.  If  labor  intervenes  in  the 
course  of  a  pneumonia  all  observers  are  agreed  that  the  strain  of  the 
labor  upon  the  already  overtaxed  heart  lessens  the  chances  of  recovery. 
If  the  pneumonia  complicates  a  puerperal  infection  it  is  usually  regarded 
as  a  terminal  infection  with  a  very  grave  prognosis. 

Treatment. — The  treatment  of  pneumonia  complicating  pregnancy 
should  be  medical  rather  than  obstetrical.  At  first  thought  it  might  seem 
that,  as  the  fetal  mortality  is  so  high  and  the  dyspnea  is  mechanically 
increased  by  the  continuance  of  the  pregnancy,  the  best  plan  would  be 
to  interrupt  the  pregnancy,  disregarding  the  life  of  the  child.  The  results 
of  this  treatment,  however,  do  not  seem  to  justify  the  procedure.  In 
the  series  of  cases  collected  by  Vinay  the  maternal  mortality  was  68 
per  cent,  when  the  pregnancy  was  interrupted,  and  only  15  per  cent, 
when  it  was  not  interrupted.  The  additional  shock  to  the  woman  arising 
from  the  induction  of  the  labor  or  the  emptying  of  the  uterus  seems  to 
turn  the  tide  against  her.  The  best  plan  seems  to  be  to  quiet  uterine 
activity  by  the  application  of  the  ice-bag  to  the  fundus  and  the  adminis- 
tration of  a  mild  opiate  as  codein,  which  also  tends  to  quiet  the  hacking 
cough  and  then  to  follow  the  usual  treatment  of  pneumonia.  If  labor 
intervenes  care  should  be  taken  to  lessen  the  shock  of  the  delivery  as 
much  as  possible  and  to  stimulate  the  heart  to  meet  the  demand  upon  it. 

Whether  the  labor  should  be  left  to  nature  or  expedited  instrumen- 
tally  depends  entirely  upon  the  progress  made  by  nature.  The  use  of 
oxygen  in  pneumonia  complicating  pregnancy  is  often  of  great  value. 
The  treatment  of  a  pneumonia  complicating  the  puerperium  depends 
upon  whether  the  infection  is  primarily  pulmonary  when  the  ordinary 
treatment  of  pneumonia  is  indicated  or  whether  it  is  secondary  to  a 
pelvic  infection.  In  the  latter  case  the  general  treatment  of  puerperal 
infection  coupled  with  careful  cardiac  stimulation  is  the  plan  to  be 
followed. 

With  the  general  hydremic  condition  of  the  blood  in  pregnancy  and 
the  unusual  demands  upon  the  heart,  pulmonary  edema  is  a  common 
accompaniment  of  a  pneumonia  complicating  pregnancy  and  the  puer- 
perium. It  should  be  constantly  watched  for  and  combated  with  dry 
cups,  oxygen,  and  cardiac  stimulants. 

Pulmonary  Embolism  Complicating  Pregnancy  and  the  Puerperium. — 
Pulmonary  embolism  is  a  very  rare  complication  of  pregnancy  and  yet 
as  a  thrombophlebitis  of  the  pelvic  or  crural  veins  occasionally  occurs 
in  pregnancy  it  must  be  considered  possible  for  a  portion  of  the  thrombus 
to  separate  and  be  carried  to  the  right  heart  and  the  pulmonary  arteries, 
the  result  depending  upon  the  size  and  niunber  of  the  pulmonary  arteries 
occluded.  A  few  cases  of  sudden  death  from  this  accident  have  been 
reported  by  Barnes^  and  others. 

Pulmonary  embolism  complicating  labor,  and  especially  the  puerperium, 
is  unfortunately  much  more  common.    It  is  one  of  the  most  tragic  events 

1  On  the  Thrombosis  and  EmboUa  of  Lj-ing-in  "Women,  Trans.  Lond.  Obstet.  Soc,  1863, 
iv,  30-53. 


468     AFFECTIONS   AND  DISEASES  COMPLICATING  PREGNANCY 

which  the  obstetrician  ever  has  to  face.  Its  suddenness,  often  when 
the  i)atient  is  apparently  convalescing  smoothly,  causes  such  a  shock 
alike  to  the  family  and  the  obstetrician  that  it  is  almost  overwhelming. 

The  obstetrician  looks  about  for  its  cause  and  wonders  if  it  could  have 
been  foreseen  or  prevented,  and  his  search  is  usually  in  vain.  While  it 
usually  follows  a  low  grade  of  infection  with  a  certain  amount  of  thrombo- 
phlebitis of  the  pelvic  veins,  hundreds  of  cases  are  seen  with  as  much  or 
greater  thrombophlebitis  without  pulmonary  embolism  and  occasionally 
it  occurs  in  the  course  of  a  puerperium,  which  has  apparently  been  per- 
fectly normal  and  afebrile.  While  it  may  occur  during  or  immediately 
following  the  labor,  it  usually  occurs  in  the  second  or  third  week  of  the 
puerperium.  It  usually  occurs  without  warning,  although  the  author 
remembers  one  case  who  complained  of  cardiac  oppression  about  twenty 
minutes  before  the  acute  dyspnea  and  symptoms  of  collapse  appeared. 
While  in  rare  cases  it  may  develop  as  a  primary  thrombus  in  the  right 
heart  itself,  it  is  usually  an  embolism  which  is  secondary  to  a  thrombo- 
phlebitis of  the  pelvic  or  crural  veins. 

The  result  depends  upon  the  extent  of  occlusion  of  the  pulmonary 
artery  or  arteries.  In  some  cases  the  main  pulmonary  artery  is  completely 
plugged,  the  patient  passes  into  a  sudden  cyanotic  pallor  with  intense 
dyspnea  and  precordial  distress,  the  pulse  disappears  at  the  wrist  and 
in  a  very  few  moments  the  patient  is  dead.  In  other  cases  the  patient 
experiences  a  sudden  pain  in  one  side  of  her  chest,  she  has  dyspnea  and 
perhaps  a  little  cyanosis  and  after  a  few  hours  she  begins  gradually  to 
recover.  On  the  following  day  there  are  often  the  physical  signs  of  a 
localized  pleurisy  with  a  slight  rise  of  temperature.  Although  this  embolic 
process  may  repeat  itself  at  the  end  of  a  week  or  more,  the  author's 
experience  has  been  that  if  the  patient  did  not  die  within  an  hour  or  so 
from  the  initial  embolism,  she  has  recovered  in  spite  of  one  or  more 
recurrences  in  what  were  apparently  small  pulmonary  arteries. 

Treatment. — Prophylactic  treatment  consists  chiefly  in  strict  asepsis 
to  avoid  as  far  as  possible  the  occurrence  of  a  thrombophlebitis.  Pul- 
monary embolism  has  occurred  w^hether  patients  after  labor  have  been 
allowed  to  sit  up  early  or  late.  It  would  seem  rational  to  the  author, 
however,  not  to  allow  a  puerperal  patient  to  sit  up  until  the  uterus  is 
well  involuted  and  the  uterine  sinuses  small. 

In  the  tragic  fulminating  type  of  pulmonary  embolism  death  usually 
occurs  so  soon  that,  as  a  rule,  all  that  can  be  done  is  to  administer  cardiac 
stimulants  and  oxygen  if  it  is  at  hand.  If  the  pulmonary  artery  plugged 
is  a  small  one  and  the  patient  recovers  from  this  embolus,  the  chief  treat- 
ment is  rest  in  order  to  avoid  a  recurrence.  As  a  rule  a  patient  should 
be  kept  in  bed  for  two  weeks  after  the  signs  and  symptoms  of  the  embolus 
have  disappeared.  The  patient  is  often  relieved  of  the  distress  of  the 
localized  pleurisy  in  the  region  of  the  embolus  by  strapping  the  chest. 

Air  Embolism. — In  spite  of  the  fact  that  air  can  be  pumped  freely 
into  the  \eins  of  certain  animals  without  causing  serious  symptoms,  as 
shown  by  Hare,  Fitzpatrick,  and  others,  there  nevertheless  remain  on 
record  certain  cases  in  which  death  has  followed  the  injection  of  air  into 


DISEASES  OF   THE  BLOOD  COMPLICATING  PREGNANCY        469 

the  liuman  uterus  for  the  purpose  of  inducing  an  abortion  or  for  other 
reasons.  On  the  other  hand,  in  many  of  the  cases  in  recent  years,  which 
at  autopsy  have  shown  air  bubbles  in  the  veins,  it  has  been  possible  as 
demonstrated  by  Dobbin  to  prove  infection  by  the  Bacillus  aerogenes 
capsulatus,  so  that  death  from  injection  of  air  into  the  pelvic  veins  of 
women  must  be  considered  very  unusual. 

DISEASES   OF  THE  BLOOD  COMPLICATING  PREGNANCY  AND  THE 

PUERPERIUM. 

As  already  stated  when  discussing  the  physiology  of  pregnancy  (see 
page  132)  the  blood  of  the  normal  healthy  pregnant  woman  does  not 
differ  markedly  from  that  of  the  non-pregnant  state.  There  is,  however, 
a  moderate  hydremia  and  a  moderate  leukocytosis  and  many  women 
enter  pregnancy  in  a  condition  far  from  normal. 

Simple  Anemia. — ]\Iany  have  been  anemic  for  years,  some  become 
pregnant  again  while  already  reduced  by  lactation  or  frequent  child- 
bearing.  Hence,  simple  anemia  is  a  common  accompaniment  of  preg- 
nancy, and  when  it  is  considered  that  the  maternal  blood  is  the  source 
of  fetal  nourishment  and  growth,  and  is  at  the  same  time  the  recipient 
of  the  effete  fetal  material,  it  is  easy  to  understand  why  many  preg- 
nant women  are  anemic,  have  low  blood-pressure,  and  need  iron  tonics, 
fresh  air,  etc.,  during  pregnancy  and  need  safeguarding  against  hemor- 
rhage, which  these  anemic  women  bear  badly,  during  labor. 

Pernicious  Anemia. — Although  a  rare  complication  of  pregnancy,  occa- 
sionally as  the  result  of  a  prolonged  simple  anemia  during  the  pregnancy, 
a  severe  toxemia  or  a  severe  postpartum  hemorrhage,  the  patient  is 
found  in  a  state  of  progressive  anemia  which  microscopic  examination 
of  the  blood  shows  to  be  a  true  pernicious  anemia.  The  literature  of  this 
subject  will  be  found  reviewed  by  Findley.^ 

Symptoms. — The  clinical  picture  is  that  usually  found  in  pernicious 
anemia.  The  extreme  yellowish  pallor,  with  dyspnea  and  progressively 
increasing  weakness;  edema  of  the  extremities,  etc.  It  is  more  often 
found  complicating  the  puerperium  than  pregnancy,  although  the  exact 
etiology  is  obscure. 

The  red  blood  cells  are  decreased  in  number.  They  are  often  irregular 
in  shape  and  some  are  nucleated.  The  hemoglobin  is  actually  decreased 
in  amount,  although  relatively  increased. 

Prognosis. — The  prognosis  is  usually  bad,  and  although  the  patient 
may  greatly  improve  under  treatment,  the  disease  usually  progresses  to 
a  fatal  issue. 

Treatment. — The  medical  treatment  which  has  proved  of  great  value 
is  the  administration  of  arsenic — Fowler's  solution — in  increasing  doses. 
Of  late  the  transfusion  of  human  blood  has  been  employed  with  marked 
success  in  some  cases.  If  the  positive  diagnosis  is  made  early  in  preg- 
nancy the  induction  of  abortion  is  certainly  justifiable  in  some  cases. 

1  Pernicious  Anemia  and  Pregnancy,  Amer.  Jour.  Obstet.,  1908,  Iviii,  51-57. 


470       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

In  conjunction  with  the  above  treatment  everything  should  be  done  to 
build  up  the  nutrition  and  general  system  of  the  patient. 

The  tendency  to  hemorrhages  found  in  pernicious  anemia  not  infre- 
quently leads  to  accidental  liemorrhage  with  j)remature  separation  of  the 
placenta  and  death  of  the  fetus. 

Leukemia. — Although  in  a  few  rare  instances  leukemia  is  found 
complicating  pregnancy,  the  connection  between  the  two  is  very  vague. 
If  the  disease  existed  prior  to  the  pregnancy  it  is  aggravated  by  the 
latter  condition.  The  diagnosis  is  suggested  by  the  profound  anemia 
and  the  enlarged  spleen  but  is  only  rendered  positive  by  the  differential 
blood  count.  According  to  Sanger^  the  fetal  blood  does  not  show  these 
changes. 

Prognosis. — The  prognosis  is  usually  bad. 

Treatment. — Induction  of  abortion,  if  the  diagnosis  is  made  early  in 
pregnancy,  is  justifiable,  but  its  value  is  problematical. 

Hemophilia. — A  true  hemophilia  is  a  rare  complication  of  pregnancy 
and  the  puerperium.  A  tendency  to  hemorrhage  from  the  different 
mucous  membranes,  from  the  alimentary  canal,  from  the  uterus,  subcu- 
taneously,  etc.,  is  often  seen  in  the  toxemia  complicating  pregnancy  and 
the  puerperium  and  hence  it  is  usually  wise  to  consider  the  hemophilia 
of  pregnancy  and  the  puerperium  as  of  toxemic  origin. 


CHRONIC  INFECTIOUS   DISEASES. 

Syphilis. — One  of  the  most  important  diseases  complicating  pregnancy 
is  syphilis,  as  three  factors  in  the  situation  are  concerned:  the  father, 
the  mother,  and  the  child. 

Paternal  Syphilis. — As  a  rule,  even  with  the  low  moral  standard  of 
some  syphilitics,  a  man  in  the  active  stage  of  syphilis  with  visible  genital 
lesions  does  not  marry.  Occasionally,  however,  this  has  taken  place  and 
the  woman  has  been  infected  with  this  dread  disease  on  her  wedding 
night  and  impregnated  at  the  same  time.  The  more  common  occur- 
rence has  been  that  the  man's  genital  lesions  have  healed  and  before 
the  days  of  the  Wassermann  reaction  he  has  supposed  himself  cured  and 
has  married  only  to  find  to  his  great  distress  later  that  he  has  infected 
both  his  wife  and  his  child. 

The  effect  of  syphilis  upon  the  mother  and  child  depends  largely 
upon  the  stage  of  the  disease  at  the  time  of  the  impregnation.  More- 
over, pregnancy  itself  has  a  marked  influence  upon  the  disease. 

Syphilis  as  Influenced  by  Pregnancy .^ — If  a  woman  becomes  infected  with 
syphilis  at  the  time  of,  or  soon  after,  impregnation,  the  local  lesions  as  a 
result  of  the  increased  vascularity  of  the  parts  become  much  more  severe 
than  in  the  non-pregnant  state.  When  the  woman  is  not  pregnant  the 
initial  lesion  of  syphilis  is  usually  small  and  inconspicuous  and  is  often 
overlooked.     During  pregnancy,  however,   the   initial  lesion  is  large, 

1  Uebcr  Leukiiniie  bei  Schwangerschaft,  etc.,  Archiv  f.  Gyn.,  1888,  xxxiii,  161-210. 


SYPHILIS  AND  PREGNANCY  471 

softer,  and  shows  a  tendency  to  ulcerate.  The  flat  condylomata  are 
also  larger,  have  more  of  a  tendency  to  spread  and  also  frequently  slough. 
Papules  show  a  tendency  to  become  pustules,  and  the  whole  disease 
presents  a  more  virulent  picture  than  in  the  non-pregnant  condition. 
The  constitutional  symptoms  of  the  infection  are  also  more  pronounced, 
with  fever  more  common  and  neuralgic  pains  throughout  the  body 
more  severe. 

Influence  of  Syphilis  upon  Pregnancy. — A  large  number  of  syphilitic 
women  as  seen  in  hospitals  and  dispensaries  have  suffered  from  an  infec- 
tion of  both  gonorrhea  and  syphilis  and  as  a  result  of  their  gonorrheal 
infection  the  fimbriated  ends  of  their  tubes  have  been  closed  and  preg- 
nancy rendered  impossible.  Hence,  quite  a  number  of  syphilitic  women 
are  sterile.  If  pregnancy  does  occur,  the  effect  of  syphilis  upon  it  depends 
largely  upon  the  stage  of  the  disease.  If  the  woman  is  already  syphilitic 
or  is  infected  at  the  time  of  impregnation,  abortion  or  premature  labor 
usually  results. 

If  a  woman  becomes  infected  with  syphilis  during  pregnancy,  the 
effect  upon  the  pregnancy  depends  largely  upon  the  period  at  which  the 
infection  occurs.  If  it  occurs  in  the  early  part  of  pregnancy,  abortion  or 
premature  labor  with  death  of  the  fetus  is  the  rule,  while  if  the  infection 
occurs  in  the  latter  part  of  pregnancy  the  child  may  go  to  term  and  be 
born  apparently  healthy.  In  more  than  50  per  cent,  of  these  cases 
(Finger),  howe^'er,  the  child  shows  a  positive  Wassermann  reaction,  and 
sooner  or  later  exhibits  manifestations  of  the  disease.  The  method  of 
transmission  of  s}'philis  from  the  father  to  the  ovum  has  been  shrouded 
with  a  good  deal  of  mystery.  It  was  for  a  long  time  supposed  that  the 
infection  was  carried  by  the  spermatozoa,  but  since  the  discovery  of  the 
Spirocheta  pallida  as  the  infecting  organism  of  syphilis  and  the  fact  has 
been  established  that  the  spirocheta  is  three  times  as  long  as  the  head 
of  the  spermatozoon  (Bab),  it  is  evident  that  the  spermatozoa  cannot 
be  the  means  of  transfer.    Two  other  possibilities  exist: 

1.  That  the  spirochetse  are  carried  by  the  spermatic  fluid  along  with 
the  spermatozoa. 

2.  That  the  mother's  blood  is  first  infected  and  the  spirochetse  are 
carried  to  the  ovum  by  her  infected  blood. 

It  is  probable  that  both  of  these  avenues  are  utilized  by  the  spirochetse. 
For  many  years  it  has  been  kno\\Ti  that  a  syphilitic  child,  infected  from 
its  father,  could  be  born  of  a  mother  apparently  free  from  the  disease  and 
could  nurse  that  mother  without  infecting  her.  This  is  known  as  Colles's 
law.  The  Wassermann  reaction  has  thrown  much  light  upon  this  con- 
dition and  it  is  now  kno^\Ti,  by  finding  that  these  women  give  a  positive 
Wassermann  reaction,  that  the  reason  they  do  not  become  infected  by 
their  syphilitic  child  is  that  they  are  already  syphilitic  themselves,  the 
infecting  organisms  having  passed  from  the  fetus  through  the  placenta 
to  the  maternal  blood  or  perhaps,  as  suggested  by  W'illiams,  they  have 
been  infected  by  syphilitic  chorionic  villi  circulating  in  the  maternal 
blood.  The  changes  produced  by  syphilis  in  the  placenta  have  been 
discussed  elsewhere  (see  page  109). 


472     AFFECTIONS  AND   DISEASES  COMPLICATING  PREGNANCY 

Evidences  of  Syphilis  in  the  Fetus. — The  usual  result  of  syphilis  in  either 
parent  is  a  stillbirth,  the  fetus  bein^j  undersized,  poorly  nourished  and 
macerated.  Occasionally,  however,  the  child  is  born  alive,  but  presenting 
the  characteristic  lesions  of  the  disease  which  should  be  familiar  to  every 
obstetrician  both  on  account  of  the  danger  of  infection  and  the  impor- 
tance of  prompt  treatment  both  of  the  child  and  the  mother.  The 
characteristic  a])pearances  are  well  shown  in  Figs.  309  and  'MO,  which 
are  photographs  of  a  case  occurring  in  the  author's  service  at  the  Sloane 
Hospital;  the  following  illustrations  of  placenta  and  cord  (Figs.  311  to  314) 
being  taken  from  the  same  case.    The  skin  is  dry  and  of  a  grayish  hue. 


Fig.    309. — Congem|al   syphilis. 
Syphilitic  bulifie  on  hands  and  feet. 


Fig.  .310. — Congenital  syphOis 
of  feet. 


Bullie  on  soles 


The  bullte  on  the  palms  of  the  hands  and  soles  of  the  feet  are  very  charac- 
teristic. The  subcutaneous  fat  of  the  body  is  largely  lacking.  ]\Iucous 
patches  in  the  mouth  and  pharynx,  and  ulcerations  about  the  anus  are 
common,  and  these  visible  lesions  may  be  considered  the  typical  evidences 
of  fetal  syphilis.  In  rare  instances,  especially  if  both  jjarents  were  free 
from  syphilis  at  the  time  of  conception,  and  the  infection  was  acquired 
in  the  latter  half  of  pregnancy,  the  child  may  appear  healthy  at  birth 
(Profeta's  law).  In  the  majority  of  cases,  however,  these  children  will 
give  a  positive  Wassermann  reaction  and  in  a  few  months  will  exhibit 
the  characteristic  lesions  of  the  disease  and  may  readily  infect  any  wet- 
nurse  to  whom  they  may  be  given  to  nurse. 


SYPHILIS  AXD  PREGNANCY 


473 


Characteristic  changes  are  present  in  the  knigs,  the  abdominal  viscera, 
and  the  long  bones. 


n?<«^   '-^^^..j 


Fig.  311. — Sj'philitic  placenta.  The  large  vessel  shows  an  obliterating  endarteritis  with 
small  round-celled  infiltration  of  its  wall.  A  small  vessel  is  nearly  occluded.  Many  of  the 
chorionic  \-illi  are  thickened,  showing  a  decreased  number  of  bloodvessels  in  their  stroma. 
There  is  round-celled  infiltration  of  the  stroma. 


Fig.  312. — Syphilitic  umbilical  cord.     Low  power.     Thickening  of  the  coats  of  the  vessel 
walls  and  infiltration  with  small  round  cells. 


474       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 


Fig.  313. — High-power  view  of  portion  of  the  wall  of  one  of  the  arteries,  marked  with  a  square 
in  preceding  figure,  showing  very  marked  round-celled  infiltration,  especially  of  the  media. 


Fig.  314. — Section  of  skin  of  feet,  showing  spiroehetae. 


SYPHILIS  AXD  PREGNANCY  475 

The  lungs  may  be  the  seat  of  gummata  or  the  alveoH  may  be  filled 
with  degenerated  epitheliiun  or  be  compressed  by  the  formation  of  new 
connective  tissue  with  round-cell  infiltration.  The  lungs  as  a  whole  are 
large  and  heavy. 

The  liver  is  markedly  increased  in  size  and  weight,  weighing  three  or 
four  times  its  normal  amount.  This  increase  in  size  is  brought  about  by 
an  increase  in  the  interstitial  connective  tissue  with  here  and  there  areas 
of  round-cell  infiltration. 

Similar  changes  are  found  in  the  spleen,  pancreas,  and  kidneys.  The 
spleen  as  well  as  the  liver  is  increased  greatly  in  size. 

Diagnosis. — The  diagnosis  of  s^^^hilis  complicating  pregnancy  is  some- 
times obscure,  but  should  always  be  suggested  by  a  history  of  repeated 
miscarriages  or  premature  labors,  and  evidences  of  the  disease  should 
then  be  searched  for  in  lesions  of  the  skin,  adenopathy',  and  the  Wasser- 
mann  test. 

Treatment. — ProphyL-\ctic. — Marriage. — Certainly  the  question  of 
eugenics  finds  no  richer  field  of  usefulness  than  in  the  prevention  of 
marriage  when  either  the  prospective  husband  or  wife  are  sj^hilitic. 
The  future  health  of  the  other  and  the  life  of  the  possible  child  depend 
upon  it.  The  question  naturally  arises,  Can  a  man  or  woman  who  has 
had  s\T)hilis  ever  marry  with  a  clear  conscience?  This  question  may 
certainly  be  answered  in  the  affirmative.  The  number  of  instances  in 
which  the  disease  has  been  cured  and  perfectly  healthy  children  have 
been  born  and  have  remained  healthy  is  sufficiently  large  to  justify  this 
answer.  One  fact,  however,  should  be  impressed  upon  all  candidates 
for  matrimony  who  have  been  syphilitic.  They  should  not  marry  until 
all  signs  of  the  disease  have  disappeared  and  the  repeated  Wassermann 
test  is  negative. 

CuKATR'E. — If  pregnancy  exists  and  either  father  or  mother  are  found 
to  be  syphilitic,  the  mother  (to  say  nothing  of  the  father)  should  at  once 
be  placed  upon  active  syphilitic  treatment,  not  only  for  her  sake,  but 
for  that  of  her  child.  She  should  be  given  salvarsan  and  the  usual  syphili- 
tic treatment.  The  transmissability  through  the  placenta  of  the  drugs 
usually  employed  in  the  treatment  of  syphilis  enables  one  to  treat  the 
fetus  as  well  as  the  mother.  The  author  in  several  instances  of  tertiary 
s\^hilis  in  the  mother  has  succeeded  in  carrying  the  pregnancy  to  a  suc- 
cessful termination  after  several  premature  deliveries  by  the  continuous 
use  during  the  pregnancy  of  small  doses  of  the  protiodide  of  mercury. 
The  child  when  born,  even  if  showing  syphilitic  lesions,  may  nurse  its 
mother  with  safety  to  her  for  the  reason  already  mentioned.  There  is  the 
gravest  danger,  however,  in  allowing  the  child  of  a  sj'philitic  father  or 
mother  to  nurse  any  other  woman,  and  this  should  never  be  allowed  even 
if  it  seems  perfectly  healthy  and  shows  no  syphilitic  lesions  at  birth. 
The.  lesions  may  appear  within  a  few  weeks  or  months  and  the  wet-nurse 
became  infected  from  the  child.  ^Moreover,  the  mother  of  a  s^3)hilitic 
child  should  never  be  allowed  to  nurse  any  other  child  even  if  she  herself 
presents  no  evidences  of  syphilis.  As  already  stated,  she  is  actually 
syphilitic  and  may  infect  a  healthy  baby  through  her  milk.    It  is  evident 


476     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

from  the  above  that  botli  mother  and  child  at  the  time  of  its  })irth  ma>' 
appear  perfectly  liealthy  and  yet  each  be  siifi"erin<;-  from  hitent  syphiHs 
and  the  mother  be  capable  of  infecting  a  healthy  baby  and  the  child  a 
healthy  woman.  From  this  it  follows  that  the  greatest  safety  in  selecting 
a  wet-nurse  lies  in  first  subjecting  her  to  a  Wassermann  test. 

Malaria  in  Pregnancy  and  the  Puerperium. — The  effect  of  malaria 
upon  a  pregnancy  depends  largely  upon  the  severity  of  the  infection. 
In  the  ordinary  type  of  malarial  infection  as  seen  in  the  northern  part 
of  the  United  States,  there  is  very  little  tendency  for  the  pregnancy  to 
be  interrui:)ted,  but  in  tropical  climates  where  the  fever  is  high  and  pro- 
longed, and  the  rigors  severe,  premature  labor  is  common.  Edmonds' 
found  this  to  be  the  case  in  Africa.  In  persons  who  have  suffered  with 
a  malarial  infection,  pregnancy,  labor  and  the  puerperium  seem  to  have 
a  tendency  to  cause  a  recurrence  of  the  attack.  According  to  Bonfils,^ 
Legeois''  and  others,  malaria  predisposes  to  puerperal  hemorrhages. 
The  fetus  occasionally  presents  evidences  of  malarial  infection  at  birth, 
i.  e.,  enlarged  spleen,  pigmentation,  etc.,  and  according  to  Bodenhauser^ 
and  Economos^  the  plasmodium  is  found  in  the  fetus.  Williams,  however, 
after  very  careful  search  in  a  series  of  15  cases,  in  which  the  plasmodium 
was  found  in  the  mothers,  was  unable  to  find  it  in  the  babies. 

Diagnosis. — From  the  natural  tendency  of  human  nature  to  avoid 
criticism  there  has  been  an  inclination  among  general  practitioners  to 
call  puerperal  infection  malaria.  The  fact  that  many  rises  of  tempera- 
ture after  confinement  subsided  under  the  use  of  (not  because  of)  quinine 
only  served  to  confirm  them  in  this  practice.  Since  the  discovery  of  the 
Plasmodium  and  the  spread  of  the  knowledge  that  its  presence  was  the 
criterion  of  malarial  infection,  this  unscientific  confusion  of  puerperal 
infection  and  malaria  is  rapidly  disappearing,  and  at  the  present  time 
the  diagnosis  of  malaria  in  the  puerperium  is  not  justified  unless  the 
])lasmodium  is  found. 

Treatment. — Malaria  in  pregnancy  and  the  puerperium  should  be 
treated  as  in  the  non-pregnant  state  and  quinine  administered  freely.  It 
should  be  borne  in  mind,  however,  that  if  the  pregnant  patient  does  not 
have  malaria,  large  doses  of  quinine  are  apt  to  bring  on  labor. 

ACUTE   INFECTIOUS    DISEASES. 

Scarlet  Fever. — This  is  an  unusual  complication  of  pregnancy  and  the 
puerperium,  not  because  pregnancy  estal)lishes  an  immunity,  but  because 
scarlet  fever  in  the  adult  is  unusual.  As  will  be  shown  when  discussing 
the  relation  between  contagious  diseases  and  puerperal  infection  (see 
page  813),  scarlet  fever  may  attack  a  pregnant  or  parturient  patient  and 
run  its  course  without  especially  affecting  the  puerperiimi  or  being  affected 
by  it. 

1  Malaria  and  Pregnancy,  Brit.  Med.  Jour.,  April  29,  1899. 

2  Paludisme  et  Puerperalite,  Ann.  de  Gynec,  1886,  xx,  14-125. 

'  Arch,  do  Tocologie,  January,  1891.  *  New  York  Med.  Jour.,  1893. 

6  Soc.  d'Obstet.  de  Paris,  February  25,  1907. 


ACUTE  INFECTIOUS  DISEASES  477 

Undoubtedly  confusion  has  arisen  in  the  past  from  the  fact  that  in 
pregnancy  as  the  result  of  a  toxemia  and  in  the  puerperium  as  the  result 
of  infection,  a  rash  may  appear  which  resembles  scarlet  fever.  For  this 
reason  the  older  statistics  of  scarlet  fever  complicating  pregnancy  should 
be  accepted  with  caution,  and  with  our  present  knowledge  of  both  con- 
ditions the  rational  view  seems  to  be  (1)  that  a  scarlet  fever  complicating 
pregnancy,  if  of  a  very  severe  type,  with  high  temperature,  may  cause 
an  abortion  or  premature  labor,  but  that  an  ordinary  course  of  scarlet 
fever  does  not  interfere  with  the  normal  course  of  pregnancy;  (2)  that 
the  danger  arising  from  scarlet  fever  complicating  pregnancy  and  the 
puerperium  comes  from  the  complications  not  infrequently  associated 
with  scarlet  fever,  i.  e.,  the  kidney  and  cardiac  lesions  and  the  strepto- 
coccic infections. 

It  is  readily  seen  that  the  kidney  lesion  of  scarlet  fever  added  to  a 
kidney  lesion  of  pregnancy  increases  the  gravity  of  the  prognosis.  More- 
over, if  the  puerperal  patient,  with  the  large,  raw  surface  of  the  parturient 
canal,  has  a  scarlet  fever  with  a  complicating  streptococcus  infection 
of  the  middle  ear  or  elsewhere,  the  risk  of  puerperal  infection  is 
increased. 

The  possibility  of  transmission  of  scarlet  fever  from  the  mother  to  the 
child  seems  well  established  by  the  cases  reported  by  Leale,^  Saffin^  and 
others. 

Measles. — On  account  of  the  relative  infrequency  of  measles  in  the 
adult,  it  is  an  unusual  complication  of  pregnancy  and  the  puerper- 
ium. The  danger  of  this  association  lies  in  the  high  temperature,  the 
complicating  pulmonary  affection,  and  the  increased  risk  of  puerperal 
infection.  Measles  during  pregnancy  is  very  apt  to  cause  abortion  or 
premature  labor,  different  observers  in  small  series  of  cases  reporting 
interruption  of  the  pregnancy  in  from  55  to  81  per  cent.  (Fellner,^  Klotz*). 
This  is  probably  caused  by  the  high  temperature  and  the  coughing. 
Although  the  complicating  streptococcic  infections  of  measles  are  usually 
less  frequent  than  in  scarlet  fever,  still  the  literature  of  the  subject  indi- 
cates a  high  mortality  from  puerperal  infection;  this  may  be  accounted 
for  in  part  by  the  relatively  large  number  of  incomplete  abortions. 
Pneumonia  also  is  a  frequent  and  dangerous  complication. 

Smallpox. — Under  the  custom  of  general  vaccination  in  this  country, 
smallpox  is  a  very  rare  complication  of  pregnancy.  When  it  does  occur 
it  is  a  very  serious  complication  both  for  the  mother  and  child.  It  is 
very  apt  to  lead  to  abortion  or  premature  labor  with  death  of  the  child. 

The  maternal  mortality,  according  to  Vinay,^  is  36  per  cent.  The 
hemorrhagic  type  is  usually  fatal  to  both  mother  and  child.  In  the  dis- 
crete variety  the  pregnancy  may  not  be  interrupted  at  the  time,  but  the 
disease  is  apt  to  be  transmitted  to  the  fetus  which  may  or  may  not  be 
killed  by  it.  One  of  the  author's  cases  was  admitted  in  labor  to  the  Sloane 
Hospital  shortly  after  her  discharge  from  a  smallpox  hospital.     The 

1  Medical  News,  1884,  p.  636.  ^  ^gw  York  Medical  Record,  April  24,  1886, 

5  Innere  Krankheiten,  Vienna,  1903.  ■*  Archiv  f.  Gyn.,  Band  xxix,  S.  448. 

5  Vaccinia  et  Variola  au  cours  de  la  Grossesse,  Lyon  Med.,  March  25,  1900, 


478       AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

child,  a  stillbirth,  was  almost  as  distinctly  pock-marked  as  the  mother, 
showing  that  it  too  had  suffered  with  the  same  disease. 

On  account  of  the  pustular  eruption  of  the  woman  the  risk  of  infection 
of  the  parturient  canal  during  any  examination  or  manipulation  is 
greatly  increased.  Hence,  the  need  of  the  greatest  care  and  the  wisdom 
of  making  as  few  examinations  as  possible. 

Treatment. — If  the  pregnant  woman  has  been  exposed  to  smallpox, 
she  should  be  ^■accinated  at  once,  the  same  as  in  the  non-pregnant  state, 
with  a  view  of  protecting  both  the  mother  and  the  fetus.  According  to 
Kollock^  the  children  of  women  who  were  vaccinated  or  had  smallpox 
during  pregnancy  are  immime  to  vaccination  and  smallpox  later.  The 
majority  of  authorities,  however,  do  not  accept  this  view  of  protection, 
and  many  cases  are  recorded  which  show  its  absence.  Certainly  the 
child  should  be  vaccinated  without  regard  to  any  possible  im- 
munity. 

Typhoid  Fever. — This  is  a  serious  complication  of  pregnancy  alike 
for  mother  and  fetus  on  account  of  the  long  duration  of  the  disease  and 
the  reduction  of  the  mother's  vitality  on  the  one  hand  and  the  risk  of 
the  interruption  of  the  pregnancy  and  the  death  of  the  child  on  the  other. 
About  50  per  cent,  of  the  pregnancies  complicated  by  typhoid  fever  are 
interrupted.  This  depends  largely  upon  the  severity  of  the  infection, 
the  height  of  the  temperature,  etc.  F.  W.  Lynch,  in  Professor  Williams's 
clinic  at  Baltimore,  demonstrated  the  typhoid  bacilli  in  the  organs  of 
the  fetus  of  a  woman  who  aborted  while  suffering  from  typhoid  fever 
and  this  observation  has  been  frequently  confirmed,  so  that  the  passage 
of  the  bacilli  and  their  toxins  through  the  placenta  to  the  fetus  must  be 
considered  important  factors  in  the  death  and  expulsion  of  the  fetus. 
In  the  author's  experience,  pregnant  patients  suffering  with  a  moderate 
degree  of  typhoid  infection  with  temperature  not  over  104°  F.  have  not 
aborted,  while  those  suffering  with  a  severe  infection  with  temperature 
frequently  reaching  105°  F.  or  over  have  aborted. 

Treatment. — The  treatment  of  typhoid  fever  complicating  pregnancy 
is  the  same  as  that  in  the  non-pregnant  state,  including  cold  bathing, 
suitable  diet,  cardiac  stimulation  where  needed,  etc.  In  addition  to 
this,  the  employment  of  the  ice-bag  on  the  abdomen  over  the  fundus 
uteri  has  seemed  to  the  author  very  valuable  in  preventing  uterine 
contractions  and  the  interruption  of  the  pregnancy. 

Cholera. — According  to  most  authorities,  cholera  is  one  of  the  most 
serious  complications  of  pregnanc>'  ever  met  with.  Schultz,-  who  in  1894 
studied  carefull\-  its  effect  upon  menstruation,  pregnancy  and  the  puer- 
perium,  found  that  jjregnancy  was  interrupted  in  54  per  cent,  of  cases 
and  that  the  maternal  mortality-  was  57  per  cent.  Accidental  hemor- 
rhages are  common  during  the  pregnancy,  as  are  changes  in  the  placenta 
and  decidua,  which  Slavjansky  has  described  as  characteristic.  Accord- 
ing to  Ballantyne,  Ti/zoni,  Cantani,  and  others,  the  disease  is  directly 

•  Amer.  Jour.  Obstet.,  1889,  p.  1079. 

2  Ueber  der  Einfluss  der  Cholera  auf  Menstruation,  Schwaugcrschaft  Geburtsh.  u.  Wochen- 
bett,  Zentralblatt  f.  Gyn.,  1894,  xviii,  1138. 


DISEASES  OF   THE  ORGANS  OF  SPECIAL  SENSE  479 

transmitted  to  the  fetus  in  idem.    The  treatment  is  the  same  as  in  the 
non-pregnant  state. 

Other  Infectious  Diseases. — Anthrax,  tetanus,  yellow  fever,  and 
certain  other  infectious  diseases  are  so  rare  as  complications  of  obstetrics 
that  students  are  referred  to  general  medical  works  for  their  study. 

DISEASES    OF    THE    ORGANS    OF    SPECIAL    SENSE. 

AfEections  of  the  Eyes  Complicating  Pregnancy. — Disturbances  of 
vision  during  pregnancy  are  of  great  importance  as  possible  indications 
of  grave  danger  either  to  the  life  of  the  woman  or  to  her  future  vision. 
The  condition  most  frequently  associated  with  disturbed  vision  in  preg- 
nancy is  a  disease  of  the  kidneys,  the  lesion  in  the  eye  being  the  so-called 
''albuminuric  retinitis"  with  white  patches  of  exudate  and  hemorrhages. 
Moreover,  a  true  optic  neuritis  is  not  infrequently  found  associated  with 
the  toxemia  of  pregnancy.  If  the  woman's  general  condition  is  much 
reduced  b}"  the  nausea  and  vomiting  of  pregnancy,  any  muscular  asthen- 
opia previously  existing  is  naturally  aggravated.  One  of  the  unusual 
ocular  complications  of  pregnancy  and  the  puerperium,  especially  as  a 
result  of  the  labor,  is  a  detachment  of  the  retina.  With  the  tendency 
to  a  lack  of  stability  of  the  nervous  system  seen  in  many  women  during 
pregnancy,  the  possibility  of  an  hysterical  amaurosis  must  always  be  con- 
sidered. During  the  puerperium  it  is  a  common  experience  to  find  a  certain 
amount  of  eye  weakness,  and  that  a  woman  in  the  first  week  or  two  after 
confinement  is  unable  to  read  or  focus  the  eyes  for  any  length  of  time  on 
a  given  object  without  more  or  less  eye  strain  and  headache.  This  is 
especially  true  if  she  has  suffered  from  profuse  hemorrhages  or  a 
toxemia. 

Diagnosis. — ^AVhile  recognizing  the  possibility  of  a  disturbed  vision  in 
pregnancy  and  the  puerperium  being  an  hysterical  manifestation,  this 
should  be  the  last  diagnosis  made.  Visiial  disturbances  in  pregnancy 
should  always  first  suggest  a  toxemia  and  should  indicate  a  careful  exami- 
nation of  the  urine.  Moreover,  if  the  vision  is  markedly  blurred,  an 
ophthalmoscopic  examination  of  the  eye  should  be  made  to  determine 
the  existence  and  extent  of  the  eye  lesion. 

Prognosis. ^The  prognosis  of  eye  lesions  in  pregnancy  is  usually  better 
than  in  the  non-pregnant  state,  but  this  depends  upon  the  location  of 
the  lesion  and  whether  the  pregnancy  is  interrupted  early  or  not.  If  the 
hemorrhages  are  not  over  the  macula  and  the  pregnancy  is  terminated 
promptly,  the  prognosis  of  restoration  of  vision  is  good.  On  the  other 
hand,  if  the  hemorrhage  is  over  the  macula,  or  if  the  optic  nerve  is 
involved,  especially  if  the  eye  signals  of  danger  are  not  heeded  and  preg- 
nancy is  allowed  to  continue  and  the  toxemia  increase,  a  permanent 
impairment  of  vision  is  probable.  It  must  also  be  borne  in  mind  that 
any  serious  eye  lesion  is  apt. to  be  made  worse  by  a  subsequent  preg- 
nancy. The  chances  of  recovery  of  perfect  vision  after  detachment  of 
the  retina  during  pregnancy,  labor,  or  the  puerperium  seem,  from  the 
cases  reported,  to  be  better  than  in  the  non-pregnant  state. 


480     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

Treatment. — This  depends  upon  the  eye  lesion,  the  presence  or  absence 
of  a  toxemia,  and  its  degree  if  present.  If,  as  is  usually  the  case,  a  toxemia 
is  present,  the  first  indication  is  to  treat  this  in  the  usual  way,  favoring 
elimination,  lowering  blood-pressure,  etc.,  and  in  this  connection  the 
importance  of  careful  and  frequent  observation  of  the  blood-pressure, 
when  ocular  symptoms  complicate  pregnancy,  should  be  emphasized. 
The  important  question  for  every  obstetrician  in  charge  of  these  cases 
to  answer  is  naturally  this:  Shall  pregnancy  be  allowed  to  continue? 
While  it  is  difficult  to  formulate  a  hard-and-fast  rule  in  these  cases  and 
the  decision  to  interrupt  the  pregnancy  should  usually  be  concurred  in 
by  a  competent  ophthalmologist,  it  may  be  said  in  general  that  retinal 
hemorrhages  usually  indicate  a  grave  toxemia  and  that  the  life,  future 
health  and  future  vision  of  the  woman  are  usually  best  safeguarded  by 
an  interruption  of  the  pregnancy.  Usually  the  vision  improves  rapidly 
after  delivery  but  a  certain  amount  of  permanent  impairment  is  not 
uncommon. 

Affections  of  the  Ears  Complicating  Pregnancy. — Aside  from  a  ringing 
in  the  ears  and  certain  nervous  disturbances  of  hearing  which  may  or 
may  not  be  due  to  a  toxemia  present,  it  is  the  experience  of  most  aurists 
and  obstetricians  that  chronic  deafness  is  made  worse  by  pregnancy  and 
that  while  the  deafness  usuall.y  improves  after  the  delivery  (especially 
if  the  woman  does  not  nurse  her  child)  the  hearing  does  not  return  to 
that  enjoyed  before  the  beginning  of  pregnancy.  ^Moreover,  each  subse- 
quent pregnancy  usually  results  in  a  still  further  impairment  with  a 
lessened  return  to  the  previous  hearing.  Lactation  from  the  tax  upon 
the  woman's  strength  and  general  vitality  seems  to  have  an  especially 
deleterious  eflfect. 

Treatment. — Patients  suffering  with  chronic  deafness  will  sometimes 
consult  their  obstetrician  as  to  the  effect  of  pregnancy  upon  their  hearing, 
and  it  is  only  fair  that  they  should  be  informed  that  it  will  probably  be 
made  worse.  The  problem  more  often  presented,  however,  is  the  question 
of  the  justification  of  interruption  of  the  pregnancy  on  account  of  an 
increasing  deafness.  This  is  often  a  difficult  question  to  answer,  as  in  it 
is  involved  the  question  of  justification  of  marriage  unless  they  were 
willing  to  run  the  risk  of  an  increasing  deafness.  Moreover,  in  man\' 
cases  the  deafness  will  increase  whether  they  become  pregnant  or  not, 
although  probably  not  so  rapidly.  In  general  it  may  be  said  that  deaf- 
ness, as  a  rule,  is  not  a  justification  for  the  interruption  of  pregnancy  and 
in  a  long  obstetrical  experience  the  author  has  only  once  felt  justified 
in  doing  it.  In  this  instance  there  were  two' sisters  under  his  care.  One 
showed  an  increasing  deafness  in  each  of  three  pregnancies  and  after  the 
third  was  almost  totally  deaf.  The  other  had  showed  an  increasing 
deafness  in  her  two  previous  pregnancies,  the  hearing  after  each  delivery 
failing  to  return  to  that  enjoyed  at  the  beginning  of  the  pregnancy.  She 
was  now  pregnant  the  third  time  and  the  husband  was  extremely  averse 
to  having  what  little  hearing  she  had  impaired.  After  a  careful  study 
of  her  sister's  experience  and  with  the  concurrence  of  two  well-known 
aurists,  the  pregnancy  was  interrupted  by  the  author. 


DISORDERS  OF   THE  ALIMEXTARY  CAXAL  .481 

Affections  of  the  Nose  Complicating  Pregnancy. — An  increased  sen- 
sibility of  tlie  olfactory  nerves  during  pregnancy  is  so  common  as  to  be 
regarded  as  physiological.  Peculiarities  in  the  sense  of  smell,  such  as 
distaste  for  the  odors  of  certain  foods,  are  often  not  only  very  marked, 
but  distressing,  causing  nausea.  The  nasal  mucosa,  especially  of  the 
lower  turbinates  and  the  septum,  is  in  a  condition  of  distinct  hyperemia 
in  pregnancy  and  this  readily  accounts  for  the  tendency  to  epistaxis 
which  is  often  seen.  The  epistaxis  in  some  cases  seems  to  be  in  the  nature 
of  a  vicarious  menstruation  and  occasionally  appears  on  the  date  which 
would  have  been  the  menstrual  period.  In  the  other  instances  it  is  the 
result  of  the  tendency  to  hemorrhage  from  the  different  mucous  mem- 
branes associated  with  a  toxemia.  In  the  cases  where  the  epistaxis 
resembles  a  vicarious  menstruation,  the  bleeding  is  usually  not  profuse 
and  little  treatment  is  needed.  On  the  other  hand,  the  epistaxis  of  a 
toxemia  is  sometimes  so  profuse  that  packing  of  the  nares  is  necessary. 
It  is  of  course  extremely  desirable  to  have  any  suppurative  process  in 
nose,  throat,  or  ears  cured  if  possible  before  the  onset  of  labor,  for  fear 
that  by  the  hands  or  the  clothing  infection  might  be  carried  to  the 
parturient  canal  during  labor  or  the  puerperium. 

DISORDERS  OF  THE  ALIMENTARY  CANAL. 

The  Mouth. — The  Teeth. — So  common  is  the  tendency  to  caries  of 
the  teeth  in  pregnancy  that  it  undoubtedly  gave  rise  to  the  old  saying, 
"For  every  child  a  tooth."  Certain  it  is  that  women  suffering  with 
carious  teeth  at  the  beginning  of  pregnancy  find  their  cavities  increase 
rapidly  in  size  as  the  pregnancy  advances  and  those  without  cavities 
at  the  onset  of  pregnancy  often  find  them  developed.  It  is  probably  due 
in  most  cases  to  the  disturbed  secretions  of  the  digestive  tract  incident 
to  pregnancy.  In  some  cases  the  dental  caries  resembles  the  mild  form 
of  osteomalacia.  As  a  result  of  the  dental  caries,  toothache  and  facial 
neuralgia  are  common  and  a  suppurating  tooth  root  may  well  be  the 
source  of  infection  of  the  parturient  canal,  the  means  of  conveyance 
being  the  hands  or  the  handkerchief. 

Treatment. — Great  care  should  be  taken  of  the  teeth  during  pregnancy, 
especially  in  the  way  of  cleanliness.  Xot  only  should  they  be  carefully 
brushed  with,  for  instance,  a  good  tooth  paste  or  powder,  but  an  alkaline 
mouth  wash  like  the  milk  of  magnesia  should  be  used  frequently.  In 
addition  to  this  the  woman  should  consult  her  dentist  at  intervals  during 
her  pregnancy  so  that  her  teeth  may  be  kept  under  observation  by  him 
and  cavities  filled  while  they  are  small.  ]\Iajor  work  on  the  teeth  during 
pregnancy  should  be  avoided,  if  possible,  on  account  of  the  danger  of 
nerve  shock  and  abortion.  Under  nitrous  oxide,  however,  a  tooth  may 
be  extracted  if  necessary  with  relatively  little  danger.  It  should  be 
borne  in  mind  that  a  toothache  or  facial  neuralgia  may  be  a  neurosis 
of  pregnancy  rather  than  the  result  of  dental  caries. 

Gingivitis. — Xot  infrequently  the  gums  during  pregnancy  become 
swollen,  soft  and  spongy,  and  bleed  easily  during  the  brushing  or  even 
31 


482     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

on  slight  touch.  This  is  best  treated  by  careful  cleansing  of  the  mouth 
with  one  of  the  good  astringent,  antiseptic  mouth  washes,  of  which 
there  are  a  number  on  the  market.  At  the  same  time  the  digestion, 
elimination,  and  general  upbuilding  of  the  patient  should  receive  careful 
attention. 

Ptyalism. — While  a  slight  increase  in  the  secretion  of  saliva  is  quite 
common  in  the  early  part  of  pregnancy,  occasionally  the  secretion  is  so 
markedly  increased  as  to  be  distinctly  pathological.  It  may  run  from 
the  mouth  almost  constantly  day  and  night,  interfering  greatly  with  the 
patient's  comfort,  preventing  sleep,  etc.  In  one  of  the  author's  patients 
the  amount  varied  between  one  and  two  pints  in  the  twenty-four  hours. 
The  ptyalism  is  usually  limited  to  the  first  half  of  pregnancy,  but  in  a 
patient  of  the  author's  it  continued  until  the  delivery  and  then  rapidly 
disappeared. 

In  mild  cases  it  may  be  the  result  of  a  reflex  irritation  of  the  sym- 
pathetic nervous  system — a  pure  neurosis,  but  in  cases  of  the  severe 
type  it  seems  to  be  one  of  the  expressions  of  a  toxemia,  other  toxic 
symptoms  being  usually  present. 

Treatment. — The  methods  of  treatment  which  usually  prove  most 
efficacious  are : 

1.  Local  astringent  mouth  washes. 

2.  The  administration  of  atropin. 

"^  3.  The  treatment  of  any  toxemia  present  by  careful  attention  to  diet 
and  elimination. 

It  must  be  admitted,  however,  that  some  cases  seem  rebellious  to  all 
forms  of  treatment,  and  the  condition  persists  until  the  delivery. 

Gastric  Indigestion. — The  physiological  or  neurotic  vomiting  of 
pregnancy  and  also  the  toxemic  or  pernicious  vomiting  have  already 
been  discussed  under  the  Physiology  and  Toxemia  of  Pregnancy  (see 
pages  131  and  417).  Not  infrequently,  however,  the  pregnant  patient 
suiTers  with  what  appears  to  be  a  pure  gastric  indigestion  with  "heart- 
l)urn"  and  for  this  she  seeks  relief. 

Treatment. — The  remedies  which  usually  prove  most  satisfactory  are 
either  bicarbonate  of  soda  or  some  preparation  of  magnesia.  The  bicar- 
bonate of  soda  may  either  be  given  in  five-grain  powders  every  three  or 
four  hours,  or,  as  is  often  more  convenient,  in  the  form  of  soda  mint 
tablets,  in  which  the  peppermint  is  sometimes  of  value.  The  magnesia 
may  either  be  given  in  the  form  of  the  milk  of  magnesia,  5j,  q-  3-4  h., 
or  some  patients  prefer  to  have  with  them  a  lump  of  solid  magnesia 
(magnesii  carbonas)  from  which  at  intervals  they  take  a  small  bite.  For 
the  digestion  giving  distress  after  meals,  a  tablet  containing  rhubarb, 
ipecac  and  soda,  as  for  instance,  rhubarb  powd.,  gr.  ij,  sodii  liicarb., 
gr.  V,  ipecac,  pulv.  gr.  |,  olei  menth.  pip.,  q.  s.,  taken  before  eating  is 
often  of  value.  In  all  cases  the  diet  of  the  patient  should  be  carefully 
attended  to. 

Constipation  and  Intestinal  Indigestion. — The  constipation  which  is 
so  extremely  connnon  in  women  at  all  times  and  especially  common  in 
pregnancy,  has  already  been  discussed  under  Management  of  Normal 


DISORDERS  OF   THE  ALIMENTARY  CANAL  483 

Pregnancy  (see  page  152).  Not  infrequently  the  pregnant  patient  suffers 
with  an  intestinal  indigestion  with  fermentation  of  the  intestinal  contents 
and  distress  from  the  gas. 

Treatment. — In  the  treatment  of  this  condition,  in  addition  to  regulating 
the  movement  of  the  bowels,  the  administration  of  an  intestinal  disin- 
fectant is  of  value.  A  formula  which  has  often  given  satisfaction  is  as 
follows : 

I^ — Sodii  phenolsulphonatis Bss 

Tr.  nucis  vomicae 3ij 

Glycerini gj 

AquEe q.  s.  ad.  Svj 

M.  Sig. — Dessertspoonful  in  water  before  eating. 

A  number  of  the  drugs  belonging  in  the  class  of  coal-tar  derivatives 
are  used  with  benefit  in  this  condition.  Aside  from  the  distress  caused 
by  intestinal  gas. in  pregnancy,  the  patient  sometimes  suffers  from  the 
pain  caused  by  adhesions  resulting  from  a  previous  operation.  This  is 
usually  most  pronounced  during  the  early  months,  while  the  uterus  is 
rising  from  the  pelvis.  Not  much  can  be  accomplished  by  treatment  of 
this  condition  save  the  assurance  that  the  adhesions,  as  a  rule,  gradually 
stretch  and  the  symptoms  lessen  as  the  pregnancy  advances. 

Gastroptosis,  Enteroptosis,  and  Movable  Kidneys. — These  conditions 
are  so  common  among  thin  women  that  they  are  commonly  met  with, 
in  the  early  part  of  pregnancy  and  the  obstetrician  finds  many  of  his 
patients  coming  to  him  wearing  different  varieties  of  abdominal  belts 
and  corsets  for  the  support  of  the  prolapsed  organs.  During  pregnancy 
the  natural  result  as  the  uterus  rises  in  the  abdomen  is  that  it  has  a 
tendency  to  elevate  the  prolapsed  organs  and  take  the  place  of  the 
mechanical  support  so  that,  as  a  rule,  a  woman  suffering  with  one  or 
other  of  these  conditions  is  usually  relieved  by  the  pregnancy.  If  she 
gains  considerably  in  flesh  during  the  pregnancy,  as  is  not  uncommon, 
the  improvement  may  be  permanent,  but  if  not,  the  former  prolapsed 
condition  of  the  abdominal  organs  tends  to  recur  after  the  puerperium. 

Appendicitis  Complicating  Pregnancy. — There  is  no  evidence  to  prove 
that  initial  attacks  of  appendicitis  are  predisposed  to  by  pregnancy  or 
that  they  occur  with  greater  frequency  than  in  the  non-pregnant  state. 
It  must  be  conceded,  however,  that  from  the  traction  on  adhesions 
about  a  chronically  inflamed  appendix  in  the  changing  size  of  the  uterus 
during  pregnancy  and  the  puerperium,  and  from  the  inevitable  trauma 
of  labor,  recurrent  attacks  are  favored  and  if  in  the  appendix  or  its  neigh- 
borhood there  is  a  pus  sac,  this  sac  may  be  ruptured  with  the  develop- 
ment of  a  suppurative  peritonitis.  Certainly  attacks  of  appendicitis 
complicating  a  pregnancy,  especially  among  those  with  a  history  of 
previous  attacks,  are  not  rare.  ReuvalV  in  1908,  collected  253  cases. 
The  diagnosis  of  appendicitis  during  pregnancy  and  the  puerperium 
often  presents  greater  difficulties  than  in  the  non-pregnant  state,  and  it 
is  often  overlooked.    A  pregnant  patient  often  suffers  with  pain  in  the 

1  Mitteilungen  aus  der  Gyn.  Klin,  des  Prof.  D.  Otto  Engstrom,  Berlin,  1908,  Band  vii, 
Heft  3. 


484     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

lower  part  of  the  abdomen  from  pressure  of  the  enlarging  uterus  and 
from  traction  on  adhesions  resulting  from  previous  pelvic  inflammation. 
As  will  be  referred  to  under  the  subject  of  Pyelitis  (see  page  601)  the 
right  ureter  is  the  one  most  frequently  enlarged  and  tender,  and  pressure 
of  the  pregnant  uterus  upon  it  often  presents  some  of  the  symptoms  of 
appendicitis.  Moreover,  in  the  latter  third  of  pregnancy,  when  the 
abdominal  wall  below  the  umbilicus  is  rendered  tense  by  the  enlarged 
uterus,  it  is  more  difficult  to  make  out  the  rigidity  of  the  rectus  or 
the  muscular  spasm  upon  which  considerable  reliance  is  placed  in  the 
diagnosis  of  appendicitis  in  the  non-pregnant. 

During  the  puerperium  there  are  several  conditions  of  the  right  tube 
and  ovary  which  may  resemble  in  part,  at  least,  an  ajjpendicitis,  such  as 
a  twist  in  the  right  appendage,  a  suppurative  inflammation,  etc.  Occa- 
sionally also  a  small  tumor  on  the  right  side  of  the  uterus  or  involving 
the  right  ovary  may  become  inflamed  and  resemble  an  appendicitis. 
Finally,  even  the  tender  uterine  body  in  puerperal  infection  may  at 
times  suggest  appendicitis.  The  only  safe  rule  is  to  always  think  of  the 
possibility  of  an  appendicitis  if  the  woman  complains  of  pain  in  the 
region  of  the  appendix,  with  an  increase  in  temperature  and  pulse  and 
with  nausea;  then  examine  carefully  the  urine,  palpate  the  pelvic  organs 
and  the  kidneys,  take  a  careful  blood  count,  and  usually  with  a  careful 
study  of  the  history  and  the  blood  count,  and  exclusion  of  inflammation 
of  the  pelvic  organs  and  the  urinary  tract,  a  correct  diagnosis  will  he 
made. 

Prognosis. — This  is  somewhat  less  favorable  than  in  the  non-pregnant, 
for  the  reason  that  with  the  dilated  vessels  and  blood  changes  of  preg- 
nancy thrombophlebitis  is  more  common,  and  the  operation  itself  is 
more  difficult  in  technic.  The  appendix  in  the  latter  half  of  preg- 
nancy is  more  difficult  to  reach,  a  longer  incision  may  be  necessary,  and 
if  the  appendix  has  ruptured  and  drainage  is  necessary,  this  is  often  more 
difficult  to  secure.  In  cases  of  perforative  appendicitis,  not  infrequently 
an  abortion  or  premature  labor  results  and  adds  to  the  gravity  of  the 
situation. 

Treatment. — Prophylactic. — Realizing  the  higher  mortality  of  appendi- 
citis in  pregnancy  as  compared  with  the  non-pregnant  state,  the  best  advice 
to  give  a  married  woman  with  a  history  of  previous  attacks  of  appendicitis, 
is  to  have  her  appendix  removed  before  she  becomes  pregnant. 

Curative. — If  a  woman  is  seized  with  an  attack  of  appendicitis  in  the 
early  half  of  pregnancy  she  should  be  treated  by  operation  the  same  as 
in  the  non-pregnant  state.  Here  the  prognosis  differs  but  little  from  that 
in  those  not  pregnant  and,  as  a  rule,  the  course  of  pregnancy  is  not 
interrupted.  In  the  latter  half  of  pregnancy  the  problem  is  a  little 
different.  On  account  of  the  increased  difficulty  of  the  operation,  the 
wiser  plan,  if  from  the  temperature,  pulse  and  blood  count  the  inflamma- 
tion seems  catarrhal  rather  than  suppurative  or  gangrenous,  is  to  treat 
the  condition  palliatively  with  rest,  ice-bags,  etc.,  with  the  hope  that  the 
operation  can  safely  be  postponed  until  after  the  puerperium.  If,  on 
the  other  hand,  the  appendicitis  gives  evidence  of  being  suppurative, 


AFFECTIONS  OF  THE  LIVER  AND  GALL-BLADDER  485 

it  should  be  treated  on  general  surgical  principles,  care  being  taken  to 
interfere  with  the  pregnant  uterus  as  little  as  possible.  The  author 
does  not  favor  the  suggestion  of  emptying  the  uterus  either  from  below 
or  by  abdominal  Cesarean  section  as  a  preliminary  step  in  dealing  with 
the  appendix. 

Ileus. — Obstruction  of  the  intestines  during  pregnancy  can  arise 
from  the  same  causes  as  in  those  not  pregnant  and  the  only  reason  for 
discussing  the  subject  in  a  work  on  obstetrics  rests  in  the  fact  that  the 
traction  of  the  enlarging  uterus  upon  a  portion  of  intestine  held  fast  by 
inflammatory  adhesions  may  bring  about  an  angulation  of  it  and  a  nar- 
rowing of  the  lumen  sujQBcient  to  cause  partial  or  even  complete  obstruc- 
tion. ]Moreover,  the  pressure  of  the  enlarged  uterus  may  still  further 
diminish  the  lumen  which  has  been  reduced  by  angulation.  The  condi- 
tion demands  the  same  surgical  attention  as  in  the  non-pregnant,  but  the 
operator  is  always  handicapped  by  the  presence  of  the  large  uterus. 

AFFECTIONS    OF    THE   LIVER    AND    GALL-BLADDER. 

Jaundice. — The  serious  lesions  of  the  liver  resulting  from  the  toxemia 
of  pregnancy  in  which  the  liver  may  undergo  the  pathological  changes 
of  acute  yellow  atrophy  and  have  jaundice  as  one  of  the  symptoms  have 
already  been  discussed  under  Toxemia  (see  page  421).  In  addition  to 
this  a  simple  catarrhal  jaundice  occasionally  occurs  in  pregnancy  as  in 
the  non-pregnant.  This,  in  itself,  is  usually  of  little  importance,  its 
interest  lying  in  the  fact  that  while  in  most  instances  jaundice  compli- 
cating pregnancy  is  an  indication  of  serious  trouble,  either  a  severe 
toxemia,  a  gall-stone  obstruction,  or  a  chloroform  poisoning,  it  may 
mean  a  simple,  catarrhal  inflammation,  which  subsides  readily  under 
restricted  diet,  and  a  few  doses  of  calomel  or  phosphate  of  soda.  Jaun- 
dice in  pregnancy,  however,  should  never  be  considered  a  simple  matter 
until  the  serious  lesions  above  mentioned  can  be  excluded. 

Gall-stones. — As  gall-stones  occur  quite  frequently  in  women  it  is 
natural  that  with  the  pressure  of  the  pregnant  uterus,  and  the  trauma 
of  labor,  attacks  of  gall-stone  colic  and  cholecystitis  should  occasionally 
be  met  with  in  pregnancy  and  the  puerperium.  Peterson,^  in  1910, 
made  a  study  of  the  condition,  collecting  25  cases  complicating  pregnancy 
and  10  cases  complicating  the  puerperium. 

In  the  25  cases  where  the  pregnancy  was  complicated  by  gall-stones, 
the  period  of  gestation  when  the  attack  first  appeared  was  recorded  in 
20  cases  as  follows : 

Attacks  prior  to  pregnancy 2  cases. 

First  appearance  during  first  month 2  cases. 

3  cases. 

2  cases. 

1  case. 

7  cases. 

1  case. 

1  case. 

1  case. 

1  Gall-stones  during  Pregnancy,  Trans.  Amer.  Gyn.  Soc,  1910,  xxxv,  84-120 


'         second 

third 

'         fourth 

fifth 

'         seventh 

'         eighth 

'         labor 

486     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

In  the  10  cases  complicating  the  piierperiimi  tlie  time  of  onset  was 
recorded  in  9  cases  as  follows: 

First  appearance  during  labor 1  case. 

"  "         first  week  of  puerperium 5  cases. 

"  "         ninth  day  "  1  case. 

"  "         tenth  day  "  1  case. 

"  "         third  week  "  1  case. 

\Yhile  it  is  desirable  to  postpone  operation  during  pregnancy  and  the 
puerperium  if  possible,  urgent  indications  for  operation  should  be  dealt 
with  as  in  the  non-pregnant  state,  even  at  the  risk  of  induction  of 
premature  labor. 

DISEASES    OF    THE   URINARY    TRACT. 

Nephritis. — The  lesions  of  the  kidneys  in  toxemia  and  the  subject 
of  ])regnancy  in  women  suffering  with  chronic  nei)hritis  have  already 
been  studied  in  the  chapter  on  Toxemia  of  Pregnancy  (see  pages  424-443). 

Lactosuria  and  Glycosuria. — Diabetes. — For  many  years  it  has  been 
known  that  the  api)lication  of  Fehling's  test  will  demonstrate  sugar  in 
the  urine  of  a  certain  number  of  pregnant  women.  This  number  varies 
in  the  experience  of  different  observers  from  1  to  o  per  cent.  In  the 
majority  of  cases  the  sugar  is  lactose  and  not  glucose,  and  the  profession 
is  indebted  to  Prof.  J.  Whitridge  Williams,'  of  Baltimore,  for  a  clear 
exposition  of  the  difference  in  clinical  significance  of  a  lactosuria  which 
is  largely  concerned  with  the  function  of  lactation  and  is  of  little  moment, 
and  a  glycosuria  which  is  of  serious  import.  The  lactosuria  which 
appears  in  early  pregnancy,  at  the  beginning  of  mammary  engorgement, 
and  again  in  the  first  week  of  the  puerperium,  as  the  function  of  lactation 
establishes  itself,  may  be  looked  upon  as  a  physiological  rather  than 
a  pathological  occurrence.  On  the  other  hand,  a  glycosuria  may  occur 
in  pregnancy  either  because  the  patient  had  diabetes  before  she  became 
pregnant,  or  it  may  originate  in  the  pregnancy  as  the  result  of  faulty 
metabolism  or  from  some  unknown  cause  associated  with  the  pregnancy 
itself.  This  glycosuria  originating  in  pregnancy  is  usually  temporary 
in  character  aufl  subsides  on  restricting  carbohydrate  diet,  or  at  any 
rate  at  the  end  of  pregnancy.  It  may,  however,  recur  in  each  subsequent 
pregnancy,  and  there  is  ground  for  believing  that  in  a  few  cases  it  becomes 
the  starting-point  of  a  true  diabetes. 

Diagnosis. — From  the  above  it  is  evident  that  the  differentiation 
between  a  lactosuria  and  a  glycosuria  is  an  important  one  and  that  the 
obstetrician  should  not  be  satisfied  to  rely  on  Fehling's  test  alone.  Fur- 
thermore, it  is  important  to  note  whether  the  glycosuria  is  constant  or 
only  temporary  in  its  occurrence  and  whether  the  amount  increases  or 
not  as  pregnancy  advances. 

Prognosis. — It  has  been  shown  that  the  prognosis  of  a  lactosuria  is 
altogether  favorable  and  need  cause  no  anxiet}'.     Furthermore,  the  prog- 

1  The  Clinical  Significance  of  Glycosuria  in  Pregnant  Women,  Amer.  ,Jour.  Med.  Sci., 
January,  1909. 


AFFECTIONS  OF  THE   URIXARY  TRACT  487 

nosis  of  a  transient  glycosuria  is  usually  favorable,  but  if  it  tends  to  recur 
and  persist  longer  and  longer  it  should  be  looked  upon  with  suspicion 
as  the  possible  forerunner  of  diabetes.  In  contrast  with  the  preceding 
pictures  is  that  of  a  woman  becoming  pregnant  while  suffering  with  real 
diabetes,  i.  e.,  with  the  excretion  of  glucose  in  the  urine  for  long  periods 
of  time  with  a  marked  increase  in  the  amount  of  the  urine  and  with  the 
constitutional  symptoms  of  diabetes.  This  is  a  rare  but  very  serious 
complication.  That  it  does  occur  is  shown  by  the  fact  that  in  1882 
Mathews  Duncan^  collected  from  the  literature  22  cases,  and  in  1909 
Williams  collected  66.  Its  seriousness  is  proved  by  the  experience  of 
every  obstetrician.  The  maternal  mortality  averages  about  50  per  cent. 
Any  severe  shock  during  pregnancy  or  the  shock  and  trauma  of  labor 
may  eventuate  in  coma  and  death.  Offergeld,-  in  a  series  of  60  cases, 
found  that  30  per  cent,  died  in  coma  and  in  about  50  per  cent,  the  disease 
had  proved  fatal  within  two  and  a  half  years.  Graefe,^  found  7  out  of  26 
cases  complicated  with  hydramnios  and  in  5  of  these  glucose  was  found 
in  the  liquor  amnii. 

The  tendenc>'  to  gangrene  after  the  trauma  of  labor  is  found  as  after 
trauma  or  operation  in  the  non-pregnant  suffering  with  diabetes.  Patients 
in  whom  the  diabetes  seems  latent  or  quiescent  before  pregnancy  often 
have  all  the  symptoms  aggravated  with  the  occurrence  and  advancement 
of  pregnancy  and  if  a  toxemia  arises,  whether  the  lesion  is  more  pro- 
nounced in  the  liver  or  in  the  kidney,  the  toxemia  and  the  diabetes  each 
act  unfavorably  upon  the  other. 

The  fetal  mortality  is  even  higher  than  the  maternal.  In  about  50 
per  cent,  the  fetus  dies  in  utero  and  is  expelled  by  abortion  or  premature 
labor  and  in  about  10  per  cent,  more  the  child  dies  within  the  first  year. 

Treatment. — This  depends  chiefly  upon  the  diagnosis.  Cases  of  lacto- 
suria  usually  require  no  treatment.  If  a  woman  has  a  true  diabetes  with 
a  constant  glycosuria,  urine  increased  in  amount  and  with  the  constitu- 
tional symptoms,  emaciation,  thirst,  etc.,  she  should  be  advised  against 
pregnancy,  and  if  pregnancy  ensues  it  should  be  interrupted.  If  a  woman 
previously  healthy  develops  a  glycosuria  in  pregnancy  she  should  be 
placed  upon  diabetic  diet,  her  digestion  and  elimination  carefully  super- 
vised, and  the  amount  of  glucose  carefully  determined  by  frequent  exami- 
nations of  the  urine.  If  it  shows  a  marked  tendency  to  become  constant 
and  increase  and  the  constitutional  symptoms  of  diabetes  begin  to  present 
themselves,  the  pregnancy  should  be  interrupted,  as  with  the  high  fetal 
mortality  inevitably  associated  with  diabetes  it  is  not  fair  to  expose  the 
mother  to  the  risk  of  true  diabetes. 

Mechanical  Disturbances  of  the  Urinary  Tract. — It  has  already  been 
stated  that  a  patient  suffering  with  movable  kidney  may  be  mechanically 
relieved  by  the  occurrence  and  development  of  pregnancy,  the  enlarging 
uterus  tending  to  hold  the  movable  kidney  in  place.    On  the  other  hand, 

1  On  Puerperal  Diabetes,  Trans.  London  Obstet.  Soc,  1882,  xxiv,  256-285. 

2  Archiv  f.  Gyn.,  Band  Ixxxvi,  Heft  1,  160. 

3  Die  Einwirkung  des  Diabetes  Mellitus,  etc.,  Graefe's  Sammlung  Zwangloser  Abhand- 
lungen,  1897,  Band  ii.  Heft  5. 


488     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

the  weight  of  the  heavy  uterus  upou  the  bladder  ofteu  gives  rise  to 
anuoying  symptoms,  especially  if  the  presenting  part  lies  low  in  the 
pelvis.  Frequency  of  micturition  is  very  common  and  this  may  interfere 
with  sleep  and  add  further  irritation  to  a  nervous  system  already  in 
unstable  equilibrium.  Furthermore,  in  the  same  way  that  the  pelvic 
pressure  may  interfere  with  the  venous  return  in  the  rectal  circulation 
and  cause  hemorrhoids  which  perhaps  will  bleed,  so  may  this  same  press- 
ure interfere  with  the  venous  return  of  the  bladder  and  perhaps  cause 
hematuria.  Mechanical  support  of  the  uterus  is  indicated  for  relief  in 
both  cases. 

DISEASES    OF    THE   DECIDUA. 

As  the  decidua  of  pregnancy  is  nothing  but  the  endometrium  of  the 
non-pregnant  which  has  undergone  certain  hypertrophic  changes  to  fit 
it  for  the  lodgement  and  nutrition  of  the  ovum,  it  is  natural  that  affec- 
tions similar  to  those  of  the  endometrium,  should  be  found  in  the  decidua. 
Recent  knowledge  has  determined  that  many  of  the  conditions  formerly 
grouped  under  the  term  "endometritis"  are  not  inflammatory,-,  but 
tro])hic,  and  that  in  many  cases  the  hyperplastic  endometrium  removed 
in  a  curettage  is  the  result  of  the  proximity  of  the  menstrual  period,  still, 
three  conditions  of  the  non-pregnant  endometrium  are  recognized: 

1.  A  hyperplasia. 

2.  An  atrophy. 

3.  A  bacterial  inflammation. 

These  same  three  conditions  are  found  affecting  the  decidua  of  preg- 
nancy. 

Hyperplasia  of  the  Decidua. — This  hyperplasia  may  be  general,  affect- 
ing both  the  interstitial  and  the  glandular  structure  of  the  decidua,  or  it 
may  affect  chiefly  either  the  interstitial  or  the  glandular  structure. 

Diffuse  Hyperplasia. — After  the  first  three  months  of  a  normal  preg- 
nancy the  decidua,  save  at  the  placental  site,  becomes  thinner  and  thinner 
as  the  pregnancy  advances.  Instead  of  this,  the  decidua  in  some  cases 
continues  the  general  hyperplastic  process  started  in  early  pregnancy. 
Into  this  thickened  decidua  in  which  both  the  interstitial  and  glandular 
portions  are  hypertrophied,  hemorrhages  frequently  take  place  which 
maj^  separate  the  fetal  membranes  from  the  uterine  wall,  or  may  even 
break  through  the  membranes  into  the  amniotic  sac.  The  usual  result 
is  the  death  and  expulsion  of  the  embryo,  either  on  account  of  the  hemor- 
rhages interfering  with  fetal  oxygenation  or  because  the  nutrition  for  the 
fetus  was  diverted  to  the  decidua.  If  the  fetus  dies  early  it  may  become 
almost,  if  not  quite,  absorbed,  and  the  thickened  decidua  be  cast  of?  as 
a  thickened  sac  lined  with  amnion — a  fleshy  mole.  On  the  other  hand, 
the  hyperplasia  may  be  gradual  and  less  in  amount  and  the  fetus  may 
rarely  reach  the  period  of  viability,  although  usually  poorly  nourished. 
At  the  time  of  the  abortion  or  labor  there  is  apt  to  be  more  or  less 
retention  of  this  thickened  decidua  with  the  tendency  to  postpartum 
hemorrhage,  sepsis,  and  subinvolution. 


DISEASES  OF  THE  DECIDUA  489 

Interstitial  Hyperplasia. — Instead  of  the  hyperplasia  bemg  general,  it 
may  affect  chiefly  the  interstitial  structure  of  the  decidua  and  be  more 
or  less  localized,  causing  projections  or  polypoid  masses  on  its  inner  sur- 
face between  the  openings  of  the  utricular  glands.  The  decidual  cells, 
including  their  nuclei,  are  very  much  enlarged.  This  is  the  Endometritis 
decidua  tuberosa,  or  Polyposa  of  Yirchow.^ 

Glandular  Hyperplasia. — The  glandular  portion  of  the  decidua  is  occa- 
sionally the  chief  seat  of  the  hyperplasia,  the  glands  secreting  an  abnormal 
amount  of  clear,  pale  yellow  fluid,  which  may  either  trickle  away  from 
the  uterus  and  vagina  almost  continuously,  or  be  stored  up  for  a  time 
between  the  decidua  parietalis  and  decidua  capsularis  and  then  be  dis- 
charged with  a  sudden  gush,  at  times  amounting  to  a  pint  or  more  in 
quantity.  This  discharge  of  fluid  in  pregnancy  has  long  been  known  as 
"hydrorrhea  gravidarum."  x\ccording  to  Van  der  Hoeven,^  the  fluid 
differs  from  liquor  amnii  in  having  a  lower  specific  gravity  and  no  albu- 
minous materials  or  urinary  elements.  Another  condition  occasionally 
occurring  in  pregnancy  and  confused  with  it  is  the  rupture  of  the  mem- 
branes high  up  above  the  cervix,  allowing  the  liquor  amnii  with  all  its 
chemical  and  physical  characteristics  to  trickle  away  from  the  uterus 
and  vagina.  As  a  rule  the  rupture  of  the  membranes  in  the  lower  uterine 
segment  usually  leads  to  the  induction  of  labor  within  thirty-six  hours. 
In  a  series  of  cases  collected  from  the  literature  by  INIeyer-Ruegg,^ 
instances  were  reported  where  labor  had  not  intervened  for  a  period 
varying  from  one  to  three  months  and  on  delivery  examination  showed 
that  the  membranes  had  contracted  about  the  fetus. 

Endometritis  Decidua  Cystica. — Occasionally  in  glandular  hyperplasia 
of  the  decidua,  the  openings  of  the  glands  become  occluded  and  small 
retention  cysts  develop  on  the  surface  of  the  decidua.  This  condition 
was  described  by  Breus,^  in  1882,  and  called  by  him  endometritis  decidua 
cystica. 

Atrophy  of  the  Decidua. — In  rare  instances,  as  described  by  Hegar^ 
and  others,  any  one  of  the  different  uterine  deciduse  (parietalis,  basalis, 
capsularis)  instead  of  undergoing  hyperplasia  may  atrophy,  with  the 
result  that  the  embryo  obtains  neither  sufficient  lodgement,  support  nor 
nutrition.  Its  etiolog}^  is  obscure.  It  usually  causes  the  death  and  expul- 
sion of  the  ovum.  If  the  decidua  capsularis  (reflexa)  is  the  one  to  atrophy 
it  allows  the  embryo  to  descend  as  the  decidua  stretches  until  it  lies  just 
over  or  within  the  cervix — the  cervical  pregnancy  of  Rokitansky. 

Bacterial  Inflammation  of  the  Decidua. — x4cute  inflammation  of  the 
decidua  may  exist  as  the  result  of  bacterial  infection  and  present  the 
typical  pathological  lesions:  swelling,  infiltration  with  leukocytes,  and 
necrosis  with  a  purulent  exudate.     It  usually  arises  from  a  gonorrheal 

1  Endometritis  decidua  tuberosa,  Die  Krankhaften  Geschwiilste,  1864,  ii,  478-480. 

2  Hydrorrhea  Gravidarum,  Monatssch.  f.  Geb.  u.  Gyn.,  1899,  x,  329-337. 

3  Eihautberstung  ohne  Unterbrechung  der  Schwangerschaft,  Zeitschr.  T.  Geb.  u.  Gyn., 
1904,  li,  419-468. 

^  Ueber  Cystose  Degeneration  der  Decidua  Vera,  Archiv  f.  Gyn.,  1882,  xix,  483-489. 
5  Kysten-bildung   in   der   Decidua,    Monatsschr.    f.    Geburtsh.,    1863,    xxi.     Supplement 
Heft  11. 


490     AFFECTIONS  AND  DISEASES  COMPLICATING  PREGNANCY 

infection  or  from  non-ase])tic  attempts  at  indnction  of  a])ortion;  ii\  the 
latter  instance  i;i\'in<i;  tlie  si<>;ns  and  syni])tonis  of  i)ueri)eral  sepsis.  Acute 
inflannnation  of  the  decidna  may  also  arise  in  the  course  of  the  exanthe- 
mata and  other  infectious  diseases,  the  bacteria  of  the  general  disease 
being  carried  to  the  lining  of  the  uterus.  The  diagnosis  would  be  made 
only  from  s\ini)toms  of  a  threatened  abortion  and  evidence  of  uterine 
infection.  Occasionally  in  the  post])artum  study  of  the  placenta  of  a 
tuberculous  patient  a  tuberculous  inflammation  of  the  decidua  with 
characteristic  cheesy  nodules  is  found. 

Hemorrhage. — In  the  course  of  the  various  changes  in  the  decidua  which 
have  been  described  it  is  not  unusual  to  have  more  or  less  hemorrhage 
occur  either  into  the  substance  of  the  decidua  or  between  the  different 
deciduse  or  between  the  decidua  and  the  uterine  wall.  The  ovum  which 
is  usually  separated  from  the  uterus  and  cast  off  as  a  result  of  these 
hemorrhages  is  often  surrounded  with  blood-clots  in  various  stages  of 
organization  giving  the  different  varieties  of  bloody  mole. 

Treatment. — The  treatment  of  the  different  changes  in  the  decidua 
wdiich  may  complicate  a  ])regnancy,  save  that  of  syphilis,  usually  has 
to  be  postponed  until  after  the  uterus  is  emptied.  Syphilitic  changes 
should  be  dealt  with  by  constitutional  treatment  of  syphilis  as  soon  as 
it  is  suspected.  In  the  treatment  of  the  other  changes  in  the  decidua 
two  principles  should  guide  one. 

1.  Make  sure  that  the  uterus  is  thoroughly  and  aseptically  emptied 
at  the  time  of  the  labor  or  abortion. 

2.  If  an  endometritis  remains  after  the  puerperium,  treat  that 
according  to  the  conditions  present;  by  a  curettage  if  necessary. 


CHAPTER  XIV. 
DISEASES  OF  THE  FETAL  MEMBRANES. 


DISEASES   OF   THE   CHORION. 

Hydatidifonn  or  Vesicular  Mole. — This  is  a  disease  of  the  chorion 
in  which  the  terminal  villi  are  converted  over  a  larger  or  smaller  area 
into  translucent  vesicles  varying  in  size  from  that  of  a  grain  of  sand  to 
cystic  masses  the  size  of  a  grape  or  even  larger  (see  Fig.  315).    In  general 


Fig.  315. — Hj-datidiform  mole. 

appearance  they  resemble  somewhat  a  bunch  of  Malagar  grapes,  but 
differ  in  that  many  of  the  vesicles  are  attached  to  each  other  rather 
than  to  the  branches  of  the  parent  stem.  The  condition  was  described 
by  Aetius,  of  Amida,  in  the  sixth  century,  but  for  many  years  no  true 
knowledge  of  the  condition  existed,  and  many  false  ideas  prevailed  as, 

(491) 


492  DISEASES  OF  THE  FETAL  MEMBRANES 

for  instance,  that  each  Acsicle  was  a  separate  ovum.  Hydatid  cysts  of 
the  liver  were  known,  and  for  many  years  this  vesicular  disease  of  the 
chorion  was  considered  to  have  some  relation  to  the  disease  which  was 
occasionally  found  in  the  liver. 

The  first  correct  explanation  of  the  condition  was  apparently  given 
by  Virchow\^  He  described  the  vesicles  as  degenerated  chorionic  villi, 
and  so  we  consider  them  today. 

Frequency.^ — In  the  Charite  Hospital  in  Berlin,  in  a  series  of  2130 
pregnancies,  hydatidiform  mole  occurred  once  in  532  cases,  while 
Madame  Boivin,  of  Paris,  found  it  only  once  in  2130  pregnancies. 
Hydatidiform  mole  is  more  common  in  multigravidse  than  in  primigravidse. 
In  the  last  10,000  cases  admitted  to  the  obstetric  division  of  the  Sloane 
Hospital  there  were  3  cases  of  hydatidiform  mole.  In  several  instances 
reported  hydatidiform  mole  has  recurred  in  subsequent  pregnancies. 

Etiology. — The  etiology  of  the  condition  is  still  obscure.  Some  author- 
ities (Mrchow,  Veit)  believe  the  condition  is  due  to  a  disease  of  the 
endometrium  and  in  support  of  this  view  may  be  mentioned  the  fact  of 
recurrence  of  the  disease  in  successive  pregnancies.  Furthermore,  Aichel,^ 
in  1901,  claimed  that  by  mechanically  interfering  with  the  circulation 
of  the  placental  site  in  pregnant  dogs  he  had  succeeded  experimentally 
in  producing  hydatidiform  mole  in  7  out  of  13  cases.  Other  authorities 
(INIarchand,  Durante,  Van  der  Hoeven)  consider  the  disease  of  ovular 
origin  and  the  changes  in  the  endometrium  secondary.  In  support  of 
this  view  may  be  mentioned  instances  of  twin  pregnancy  in  which  one 
fetus  is  normal  with  normal  placenta  and  the  other  ovum  is  an  hydatidi- 
form mole.  Another  argument  favoring  the  view  of  ovular  origin  is  the 
fact  that  in  many  cases  all  traces  of  the  fetus  have  disappeared,  showing 
that  the  mole  developed  very  early  in  pregnancy  before  the  ovum  was 
likely  to  have  become  very  deeply  imbedded  in  decidua  or  to  have 
received  very  much  nourishment  from  it.  While  the  arguments  in  favor 
of  the  ovular  origin  seem  rather  stronger  than  those  of  the  endometritic, 
it  has  to  be  admitted  that  at  present  the  exact  etiology  is  unknown. 

Pathology. — The  vesicular  degeneration  of  the  chorion  usually  begins  in 
early  pregnancy  and  usually  involves  the  whole  chorion.  As  a  rule  the 
fetus  dies  and  is  absorbed  so  that  no  trace  of  it  is  foimd.  Occasionally, 
however,  the  disease  apparently  begins  later  in  the  pregnancy  and  is 
less  in  extent,  so  that  the  nutrition  of  the  fetus  is  not  markedly  interfered 
with,  and  it  may  be  born  alive  with  one  portion  of  the  placenta  showing 
vesicular  degeneration.  This  occurrence  of  a  living  fetus  with  a  placenta 
partially  degenerated  into  vesicles  makes  it  seem  probable  that  the  fetal 
death  usually  occurring  in  early  pregnancy  is  the  result  of  chorionic 
degeneration  rather  than  its  cause,  as  has  been  suggested  by  some. 
Hydatidiform  mole  is  not  confined  to  uterine  pregnancies,  but  has  also 
been  found  in  cases  of  ectopic  gestation.  On  microscopic  examination 
changes  are  found  both  in  the  stroma  of  the  villi  and  in  the  epithelial 

1  Myxoma  der  Placenta,  Die  Krankhaften  Geschwiilste,  1863,  i,  405-414. 

2  Ueber  die  Blasenmole,  eine  experimentelle  Studie,  Verh.  der  Deutsch.  Ges.  f.  Geb.  u. 
Gyn.,  1901. 


DISEASES  OF   THE  CHORION 


493 


covering,  more  marked,  however,  in  the  latter.  In  the  stroma  the  change, 
according  to  Marchand,^  ig  chiefly  an  edema,  although  as  the  process 
advances  the  bloodvessels  of  the  terminal  villi  disappear,  the  stroma  cells 
become  necrotic  and  do  not  stain  well.  The  changes  in  the  syncytium 
and  in  Langhans's  layer  of  cells  is  most  marked.  They  both  proliferate 
irregularly  and  luxuriantly.  In  each  layer  along  with  the  proliferation, 
occurs  a  certain  amount  of  degeneration  and  necrosis,  producing  numerous 
vacuoles.  One  characteristic  of  these  two  epithelial  layers  in  an  hydatidi- 
form  mole  is  their  tendency  to  erode  and  penetrate.  The  Langhans's 
layer  in  places  penetrates  the  syncytium;  they  both  penetrate  Nitabuch's 


Fig.  316. — Hydatidiform  mole  perforating  the  uterine  wall.      (Bumm.) 

fibrin  layer,  the  natural  outer  boundary  of  the  ovum;  they  burrow  into 
the  decidua  and  in  some  cases  they  not  only  penetrate  but  even  per- 
forate the  uterine  musculature,  so  that  the  vesicles  may  be  found  project- 
ing through  the  uterine  wall  (see  Fig.  316).  These  perforating  moles  are 
not  necessarily  malignant  but  easily  lead  to  rupture  of  the  uterus  and 
severe  hemorrhage  during  labor,  abortion  or  surgical  manipulation  for 
emptying  the  uterus.  The  so-called  syncytial  wandering  cells  which 
are  found  in  the  regenerating  endometrium  and  occasionally  in  the 


'  Ueber  den  Bau  der  Blasenmole,  Zeitschr.  f,  Geb.  u.  Gyn.,  1895,  xxxii,  206-216. 


494  DISEASES  OF  THE  FETAL  MEMBRANES 

musculature  near  it  after  a  normal  pregnancy  are  usually  more  abundant 
in  the  case  of  an  hydatidiform  mole.  A  few- degenerated  chorionic  villi 
are  occasionally  found  to  have  penetrated  the  wall  of  one  of  the  uterine 
veins  and  found  their  way  into  the  lumen  along  which  they  may  be 
carried  by  the  blood  current.  Along  with  the  local  disease  of  the  chorion 
there  may  be  associated  the  usual  complications  of  pregnancy,  such  as 
the  various  phases  of  toxemia,  pernicious  vomiting,  with  its  liver  necrosis, 
nephritis,  etc.    The  breasts  show  the  usual  changes  of  pregnancy. 

Occasionally  associated  with  an  hydatidiform  mole  are  found  multi- 
locular  lutein  cysts  of  the  ovaries.  This  association  is  not  constant, 
but  is  frequent  enough  to  arouse  speculation  as  to  a  possible  etiological 
connection.  FriinkeP  claims  that  at  least  100  cases  of  this  complication 
are  on  record.  These  cysts,  according  to  Frankel,  are  multilocular,  but 
each  seems  to  project  from  the  surface  of  the  ovary,  rather  than  lie 
as  daughter  cysts,  as  in  the  ordinary  cystadenoma.  They  average 
about  the  size  of  a  grape,  although  occasionally  the  combined  cystic 
mass  may  reach  the  size  of  an  orange.  They  are  filled  with  clear  fluid 
and  their  walls  are  lined  with  one  or  more  layers  of  lutein  cells.  In  a  few 
of  the  cases  reported  (Frankel)  retrogression  has  been  noticed  in  the 
cysts  after  the  uterus  was  emptied  of  the  hydatidiform  mole.  Although 
these  lutein  cysts  have  been  noted  as  involving  one  or  both  ovaries 
by  numerous  observers  (Marchand,  Stoeckel,  Runge,  Jatfe),  their  etio- 
logical relation  to  the  hydatidiform  mole  has  never  been  thoroughly 
established. 

Prognosis. — E\ery  obstetrician  of  large  experience  has  met  with  cases 
of  hydatidiform  mole  in  which  the  uterus  was  emptied  and  in  which 
there  was  no  recurrence  of  the  mole,  although  the  woman  subsequently 
bore  children.  The  author  has  recently  delivered  a  patient  of  her  third 
living  child,  although  her  first  pregnancy  resulted  in  an  hydatidiform 
mole.  Hence  it  must  be  recognized  that  a  certain  type  of  hydatidiform 
mole  is  non-malignant.  On  the  other  hand,  about  50  per  cent,  of  the 
cases  of  chorio-epithelioma  (Eiermann)  which,  although  in  a  few  cases 
presenting  a  low  grade  of  malignancy,  usually  is  the  most  tragically 
malignant  disease  to  which  woman  is  subject,  are  preceded  by  an  hydatidi- 
form mole.  This  gives  at  least  presumpti\'e  evidence  that  there  is  some 
connection  between  hydatidiform  mole  and  chorio-epithelioma.  More- 
over, the  fact  that  cases  of  hydatidiform  mole  occur  which  penetrate  and 
even  perforate  the  uterine  wall  (see  Fig.  316),  shows  that,  even  if  per- 
manent recovery  follows  removal  of  the  uterus  in  these  cases,  hydatidi- 
form mole  may  be  at  least  destructive.  Moreover,  the  fact  that  in  a 
few  cases  of  hydatidiform  mole,  at  varying  intervals  after  the  expulsion 
of  the  mole,  metastases  of  vesicular,  degenerated  villi  are  found  in  the 
vagina  or  vulva,  shows  that,  even  if  there  is  no  recurrence  after  removal 
of  these  metastases,  there  is  certainly  a  resemblance  in  some  cases  between 
the  behavior  of  hydatidiform  mole  and  chorio-epithelioma.  Finally, 
it  must  be  agreed  that  between  the  non-malignant  hydatidiform  mole 

1  Die  Histologic  der  Blascnmole  und  ihre  Beziehungen  zu  den  maligiien  von  den  Chorion 
Zotten  ausgehcnden  Utcrustunioren,  Zeitschr.  f.  Geb.  u.  Gyn.,  Band  xli,  S.  520. 


DISEASES  OF   THE  CHORIOX  495 

on  the  one  hand  and  the  rapidly  malignant  chorio-epithelioma  on  the 
other,  there  are  certain  types  of  hydatidiform  mole  which  occupy  a 
transitional  ground.  Furthermore,  pathologists  are  agreed  that  at 
present  they  are  unable  to  determine  microscopically  which  hydatidiform 
mole  is  to  prove  absolutely  benign  and  which  is  to  assume  a  destructive 
type. 

Signs  and  Symptoms. — One  of  the  first  signs  of  an  hydatidiform  mole 
is  an  enlargement  of  the  uterus  beyond  the  size  expected  at  that  period 
of  pregnancy.  Coupled  with  this  is  the  inability  of  the  obstetrician  to 
hear  the  fetal  heart  and  the  inability  of  the  woman  to  feel  fetal  move- 
ments, although  the  uterus  is  larger  than  the  size  at  which  both  of  these 
are  usually-  detected.  Thus  at  three  or  four  months  the  uterus  may  be 
at  the  level  of  the  umbilicus  and  yet  neither  fetal  heart  or  fetal  movements 
be  capable  of  detection.  One  of  the  characteristics  of  an  hydatidiform 
mole  is  an  irregular  hemorrhage  or  serosanguineous  discharge,  which 
may  occur  at  any  time  and  usually  continues  at  varying  intervals  until 
the  mole  is  removed  by  nature  or  by  the  obstetrician. 

Diagnosis. — In  the  discharge  there  occasionally  appear  some  of  the 
characteristic  vesicles  of  the  mole.  From  these  the  diagnosis  is  eas.y, 
but  as  this  sign  is  often  absent  the  diagnosis  in  many  cases  has  to  be 
made  from  the  excessive  size  of  the  uterus,  its  boggy  feel  and  the  absence 
of  fetal  heart  sounds  and  fetal  movements.  In  some  cases  without  hemor- 
rhage it  may  be  almost  impossible  to  diagnose  an  hydatidiform  mole  from 
a  dead  fetus  with  hydramnios  until  the  uterus  is  explored. 

Treatment. — As  soon  as  the  diagnosis  is  made  the  uterus  should  be 
emptied  both  on  account  of  the  risk  of  the  groT\i:h  perforating  the  uterus 
and  causing  its  rupture,  with  severe,  perhaps  fatal,  hemorrhage,  and 
also  on  account  of  the  risk  of  the  development  of  a  chorio-epithelioma 
with  all  its  dire  consequences.  In  emptying  the  uterus  the  greatest  care 
should  be  observed  lest,  in  the  manipulation,  the  uterine  wall,  weakened 
by  the  inroads  of  the  growth,  give  way.  After  the  dilatation  of  the  cervix 
the  gloved  finger  is  the  safest  instrument  to  be  used  in  the  removal  of 
the  grov^i:!!  and  after  its  removal  or  expulsion  the  uterine  cavit}'  should 
be  carefully  palpated  to  make  sure  that  it  is  empty.  It  is  usually  wise 
to  pack  the  uterine  cavity  with  gauze  after  removing  an  hydatidiform 
mole  to  provide  against  hemorrhage. 

A  patient  after  the  removal  of  an  hydatidiform  mole  should  be  watched 
for  several  months  with  great  care  and  any  intermenstrual  hemorrhage 
should  be  looked  upon  as  suggestive  of  chorio-epithelioma.  A  curettage 
should  be  promptly  performed;  the  curettings  carefully  examined  and  if 
chorio-epithelioma  is  found  a  radical  hysterectomy  should  be  performed 
with  the  hope  that  the  disease  is  localized. 

Chorio-epithelioma. — One  of  the  most  tragic  results  of  a  pregnancy, 
terminating  either  as  an  abortion  or  a  full-term  labor,  is  the  development 
of  a  rapidly  fatal  malignant  groT\i:h  composed  of  both  layers  of  the  chorio- 
nic epithelium — the  syncytium  and  Langhans's  layer  and  called  a  cliorio- 
epitheJioma  (see  Fig.  317).  This  growth  may  show  itself  during  the  first 
week  after  an  abortion  or  full-term  labor,  or  may  not  appear  for  a  nmuber 


496 


DISEASES  OF  THE  FETAL  MEMBRANES 


of  months.  In  about  50  per  cent,  of  the  cases  as  already  stated,  it  has 
been  preceded  by  the  growth  of  an  h\'datidiform  mole  and  in  a  few  cases 
it  has  been  found  developed  before  the  uterus  was  emptied  either  of  the 
embryo  or  the  mole.  The  literature  of  the  subject  appears  to  begin  with 
the  paper  of  Stinger/  who  in  1892,  reported  the  autopsy  of  a  case  which 
died  seven  months  after  an  abortion  at  the  eighth  week.  In  this  case 
there  were  soft,  reddish  tumors  in  the  uterine  wall  and  metastases  in  the 


A 

/ 


r      / 
B 


Fig.  317. — Chorio-epithelioma,  showing  involvement  of  uterus,  vagina  and  broad  liga- 
ments:   A,  primary  growth;  B,  metastases  in  broad  ligament;  C,  metastases  in  vagina. 


lungs,  one  of  the  ribs,  the  diaphragm  and  in  the  right  iliac  fossa.  Sanger 
considered  the  cells  found  in  these  tumors  as  of  decidual  origin  and  the 
growth  a  sarcoma  deciduocellulare.  This  view  was  generally  accepted 
until  Marchand,^  in  1895,  and  again  in  1898,  published  the  results  of 

•  Deciduoma  Malignum,  Verhandl.  d.  deutschen.  Gcsellsch.  f.  Gyn.,  1892,  iv,  333. 

2  Ueber  die  sogcnannten  "decidualen"  Geschwiilste,  etc.,  Monatssehr.  f.  Geb.  u.  Gyn., 
1895,  i,  419-438,  513-560;  Ueber  das  Maligna  Chorion  EpitheHom,  nebst  Mittheilung  2 
neuer  Fiille,  Zeitschr.  f.  Geb.  u.  Gyn.,  1898,  xxxix,  173-258. 


a 
I 

0 

't. 

0 

u 


CHORIO-EPITHELIOMA  497 

his  experience  and  studies  which  proved  that  the  growths  were  of  epithehal 
origin,  were  fetal  rather  than  maternal,  and  that  both  layers  of  the 
chorionic  epithelium  were  found  in  them.  He  gave  to  the  growth  the 
name  oi  chorio-epithelioiiia,  and  his  views  regarding  its  pathologv  have 
held  until  the  present. 

Frequency.— Since  the  publication  of  Sanger's  first  case  in  189'^  the 
reports  of  similar  cases  have  been  numerous  and  frequent,  so  that  con- 
siderable literature  has  accumulated.  Two  cases  presented  themselves 
m  the  author  s  service  at  the  Sloane  Hospital  within  a  few  months 
Jrig.  ob  and  Plate  M  represent  the  pathological  findings  in  one  of 
them. 

Etiology.— The  cause  of  chorio-epithelioma  is  unknown  save  for  the 

tact  that,  as  already  stated,  in  about  one-half  the  cases  it  is  preceded  bv 

.  an  hydatidiform  mole.    It  seems  to  have  the  tendencv  to  proliferate  and 

burrow,  which  is  characteristic  of  certain  hydatidiform  moles  turned 

Pathology.— The  primary  growth  is  usually  located  in  the  uterine  cavitv 
at  the  p  acental  site.    It  is  a  soft  vascular,  purplish  mass,  somewhat  resem- 
blmg^a  hematoma.    Although  this  is  the  usual  site  it  is  not  universallv 
so.    Cases  ot  ectopic  gestation  have  been  followed  bv  a  chorio-epithe- 
lioma with  Its  primary  focus  in  the  tube  (Davidson,  WiUiams)      Other 
cases  are  on  record  where  the  primary  growth  was  in  the  vagina  and 
the  uterus  seemed  free  from  the  disease;  the  chorionic  epithelium  which 
may  be  transplanted  in  a  normal  pregnancy,  in  this  case  having  under- 
gone a  mahgnant  change.    Chorio-epithelioma  has  been  found  associated 
with  certain  teratomata  of  the  testicle  and  the  ovary  (Schlagenhaiifer 
Risel  Pick  and  others).    Here  it  seems  to  have  arisen  from  the  undifferen- 
tiated fetal  ectoderm  m  the  teratoma.     The  growth,  as  a  rule,  rapidlv 
erodes  and  penetrates  the  venous  channels  and  hence  metastases^  ar'e 
recjuent  and  occur  early.     The  most  frequent  site  of  these  metastases 

nv    vlr-f"l'f  ^"""  ^^!''  ^^^  ^}''\  ^"  '^''  °^^j°^^^^^  °f  ^^«^«  become 
imoliedif  the  case  is  to  prove  fatal.     The  next  most  frequent  site  of 

metastasis  is  m  the  vagma  and  the  diagnosis  of  a  uterine  chorio-epithe- 
lioma can  often  be  confirmed  by  finding  in  the  vagina  a  purplish  hemor- 
dischar  r°'  ^'""^'^  """^     ■ '  ""''"^  ''  ''^''^^^^'  accompanied  by  a  foul 

Other  sites  of  metastasis  are  in  the  liver,  kidneys,  spleen,  the  con- 
nective tissue  of  the  broad  ligament,  the  bones,  and  the  brain.  Lutein 
cystomata  of  the  ovaries  are  at  times  found  associated  with  chorio- 
epithehomata  as  they  are  with  hydatidiform  moles,  but  as  in  the  latter 
case  no  etio  ogical  connection  has  been  established.  Microscopicallv 
chorio-epithehomata  show  blood  spaces  surrounded  bv  masses  of  svncvt- 
mm  and  proliferated  Langhans's  cells.  According  to  Marchand  and  Risel 
the  growth  may  be  either  typical  or  atypical.  In  the  former  the  cells' 
resemb  e  those  of  the  chorionic  epithelium  of  early  pregnancv,  while  in 
the  latter  the  growth  more  nearly  resembles  a  sarcoma,  the  infiltration 
being  more  diffuse  and  consisting  of  irregular  groups  of  less  clearly 
defined  syncytial  and  Langhans's  cells.  ^ 


498  DISEASES  OF  THE  FETAL  MEMBRANES 

Clinical  Picture.—  ('lu)ri()-cj)itlu'li()nia  iiia\  follow  any  pregnancy,  at  any 
age  and  whatever  the  period  of  its  termination.  Its  existence  should 
always  be  suggested  if  after  a  labor,  abortion  or  expulsion  of  any  hydat- 
idiform  mole  the  woman  has  a  hemorrhage  which  tends  to  persist  and 
which  is  associated  with  a  cachexia,  an  enlargement  of  the  uterus  and  a 
foul  discharge.  This  suspicion  is  rendered  still  more  probable  if  a  soft, 
hemorrhagic  growth  is  found  in  the  vagina.  The  clinical  picture  will 
perhaps  be  rendered  clearer  by  the  history  of  one  of  the  author's  cases. 

A  German  woman,  aged  thirty-three  years;  married;  admitted  on 
September  11,  1911,  with  the  following  history: 

Family  history  of  no  significance. 

Menstrual  hidory  began  at  the  age  of  sixteen  years,  irregular  in  type, 
flowing  every  three  to  four  weeks  for  four  or  five  days,  with  a  rather 
profuse  discharge  of  blood,  preceded  by  severe  pain. 

Marital  History. — The  patient  had  been  married  for  the  last  eleven 
years  and  had  been  jiregnant  three  times;  one  miscarriage  four  years 
ago,  necessitating  a  curettage;  one  full-term  child;  and  a  six  month's 
miscarriage  eight  weeks  before  admission. 

Present  History. — From  the  second  to  the  sixth  month  of  her  last 
pregnancy  the  patient  had  repeated  small  hemorrhages  until  at  the  end 
of  the  sixth  month  she  gave  birth  to  a  fetus,  which  is  said  to  have  lived 
one  day.  From  this  time  up  to  the  day  of  admission,  a  period  of  eight 
weeks,  the  patient  continued  to  have  a  bloody  vaginal  discharge.  She 
was  not  under  observation  during  this  time  and  received  no  medical 
treatment.  The  flow  was  said  to  have  been  profuse  and  almost  without 
intermission.  Clots  were  frequently  passed.  The  patient  became  pro- 
gressively weaker.  There  was  loss  of  appetite,  strength  and  flesh.  During 
the  last  few  weeks  there  were  frequent  attacks  of  faintness  and  actual 
loss  of  consciousness.  She  complained  of  a  continuous  pain  in  the  left 
loin  and  back,  constantly  growing  worse.  During  the  last  two  weeks 
there  was  a  cough  with  blood-tinged  sputum.  The  bowels  were  con- 
stipated, but  of  bladder  symptoms  there  were  none. 

The  {physical  examination  presented  the  following  points  of  interest: 
The  patient  was  of  a  sallow,  lemon  color,  ob^'iously  anemic  and  showing 
evidence  of  recent  loss  of  flesh.  She  was  scarcely  able  to  w^alk.  The 
heart  action  was  rapid,  the  sounds  of  poor  quality,  but  no  murmurs 
were  present.  Examination  of  the  lungs  revealed  over  the  right  lower 
lobe  many  fine,  subcrepitant  rales.  Breath  sounds  were  diminished, 
but  there  was  no  impairment  of  resonance.  Otherwise  the  lungs  seemed 
normal.  The  abdomen  was  flabby,  with  recent  strise,  and  the  muscle 
tone  poor.  The  fundus  uteri  could  be  felt  four  fingers'  breadth  below  the 
umbilicus.  Vaginal  examination  showed  the  perineum  to  be  relaxed 
and  there  was  a  moderately  profuse  serosanguinous  discharge.  On  the 
right  side  of  the  posterior  vaginal  wall  was  a  tumor  the  size  of  a  hickory 
nut,  bluish  in  color,  irregular  in  outline  and  firm  in  consistency.  The 
cervix  was  soft  and  easily  admitted  the  examining  finger,  revealing  to 
it  a  spongy,  friable  mass  in  the  cavity  of  the  uterus  which  bled  freely. 
The  uterus  was  large,  as  indicated,  and  not  freely  movable. 


DISEASES  OF  THE  CHORION  499 

On   admission    the    temperature    was    101.2°,   pulse    120,    and    the 
respirations  38. 
The  blood  count: 

Red  blood  cells 2,972,000 

White  blood  cells 18,000 

Polynuclear  leukocytes 80  per  cent. 

Lymphocytes 20  per  cent. 

Hemoglobin 50  per  cent. 

The  urine  was  acid,  1032,  a  trace  of  albumin,  no  sugar.  Microscopic 
examination  showed  a  moderate  number  of  red  blood  cells,  epithelial 
cells,  and  urates. 

Diagnosis. — Chorio-epithelioma. 

Operation  was  not  considered  advisable  because  of  the  presence  of 
metastases  in  the  vagina  and  lung,  and  because  of  the  presumption  that 
they  existed  in  uterosacral  and  broad  ligaments  as  indicated  by  the  lack 
of  mobility  of  the  uterus.  The  general  condition  of  the  patient  as  well 
was  so  poor  as  to  render  her  a  bad  operative  risk. 

The  patient  lived  for  twenty-three  days  after  admission,  running  a 
typical  septic  temperature,  ranging  from  normal  to  105.8°  F.  The  pulse- 
rate  averaged  about  130,  often  reaching  160.  During  the  last  four  days 
the  temperature  was  subnormal.  Examination  of  the  lungs  from  time 
to  time  showed  an  extension  of  the  signs  first  noted  in  the  right  lower 
lobe,  until  fine  subcrepitant  rales  could  be  heard  all  over  both  lungs. 

Another  tumor  mass  appeared  in  the  vagina  similar  to,  though  smaller 
than,  the  one  originally  observed,  which  meanwhile  had  ulcerated.  The 
cough  and  bloody  expectoration  became  aggravated  and  the  serosan- 
guinous  vaginal  discharge  continued  to  the  end. 

An  abstract  of  the  pathologist's  report  of  the  autopsy  findings  is 
given  below : 

"  Anatomical  Diagnosis. — Chorio-epithelioma  of  the  uterus  with  exten- 
sion into  the  uterosacral  ligaments.  Metastases  in  the  vagina,  lungs  and 
liver. 

"Lungs  (see  Plate  VI)  studded  with  nodules  varying  from  0.5  to  3 
cm.  in  diameter.  Some  are  pale  but  most  are  deep,  dusky  red.  They 
show  deep  umbilication  and  two  seem  to  have  penetrated  the  pleura. 
On  section  they  form  irregular  masses  through  the  lung  tissue  and  there 
is  much  hemorrhage  into  their  substance,  and  the  centres  of  some  of  the 
larger  nodules  are  softened.    The  bronchial  lymph  nodes  are  not  invaded. 

"Uterus  (see  Fig.  317)  moderately  enlarged.  The  cavity  is  lined 
with  a  layer  of  deep  red,  necrotic  tissue,  3  to  4  mm.  thick,  which  extends 
into  a  large  necrotic  mass,  4  cm.  in  diameter  in  the  left  uterine  wall  (A). 
It  has  perforated  the  muscle  posteriorly  and  become  adherent.  The 
centre  is  semifluid  and  exceedingly  foul.  It  extends  out  into  the  lower 
portion  of  the  left  broad  ligament  (B),  and  there  is  a  nodular  tumor  about 
2  cm.  in  diameter  in  the  right  uterosacral  region  (B),  which  is  deep  red 
but  not  broken  down.  There  are  3  nodules  in  the  vaginal  wall,  1  cm. 
in  diameter,  two  of  which  are  ulcerated  on  the  surface  and  necrotic^in 
the  centre;  the  third  is  well  preserved  (C,  C,  C). 


500  DISEASES  OF  THE  FETAL  MEMBRANES 

"Liver  much  enlarged,  reddish-yellow  in  color.  In  the  right  lobe 
are  two  small,  deep  red  nodules." 

Sections  cut  from  the  primary  growth  showed  microscopically  an 
invasion  of  the  uterine  musculature  by  groups  of  large  multinuclear 
cells  (syncytial  masses).  The  metastatic  nodules  in  lungs  and  liver 
showed  a  similar  in\'asion  by  the  cells  of  the  new  growth.  Both  primary 
and  secondary  foci  were  characterized  by  hemorrhagic  areas. 

Diagnosis. — This,  although  perhaps  suggested  by  the  history,  is  usually 
not  positively  made  till  either  curettings  from  the  uterus  or  a  portion 
of  the  vaginal  growth  is  subjected  to  a  microscopic  examination.  It 
is  especially  important  to  emphasize  here  the  value  of  subjecting  to 
microscopic  examination  the  curettings  of  every  case  which  has  recently 
been  pregnant  unless  the  tissue  removed  is  evidently  normal  chorion. 

Treatment. — AVhen  once  the  diagnosis  has  been  made,  the  only  hope 
from  treatment  lies  in  the  early  radical  removal  of  the  uterus,  tubes, 
ovaries,  and  upper  part  of  the  ^■agina.  Even  then  operation  is  hopeless 
if  the  lungs  and  other  organs  are  involved  in  metastases.  Hence  the 
woman  should  be  carefully  examined  for  evidences  of  general  metastases 
and  if  these  are  found  operation  should  not  be  performed.  Although 
cases  occur  in  which  these  growths  are  found  in  the  vagina  and  not  in 
the  uterus,  the  author  does  not  believe  it  rational  to  simply  remove  the 
vaginal  growths  and  run  the  risk  of  leaving  behind  a  uterine  growth 
which  may  not  be  apparent. 

During  the  year  1915  the  author  has  operated  upon  two  cases  of 
chorio-e])ithelioma,  each  preceded  by  an  hydatidiform  mole.  In  both 
cases  the  disease  was  limited  to  the  uterus  and  both  made  good 
recoveries  after  a  complete  hysterectomy. 

DISEASES    OF    THE   AMNION. 

Abnormal  Amount  of  Liquor  Amnii. — The  amount  of  liquor  amnii  in  a 
given  case  may  either  be  above  or  below  that  usually  present.  An  exces- 
sive amount  is  spoken  of  as  hydramnins,  polyhydramnins,  dropsy  of  the 
amnion,  etc.    An  amount  below  the  normal  is  called  oligohydramnios. 

Hydramnios. — The  amount  of  liquor  amnii  varies  greatly  in  individual 
cases  which  are  regarded  normal.  Thus  a  variation  of  from  one  to  two 
pints  is  not  considered  abnormal.  On  the  other  hand  the  amount  is 
sometimes  enormous,  in  rare  cases  reaching  several  gallons.  The  first 
question  then  is  what  shall  be  considered  a  dividing  line  between  the 
normal  and  the  abnormal.  This  must  be  more  or  less  arbitrary,  but  in 
general  any  case  having  an  amount  of  liquor  amnii  over  two  quarts  is 
considered  one  of  hydramnios. 

Frequency. — Cases  of  slight  excess  of  liquor  amnii  are  relatively  common, 
while  those  with  marked  excess  producing  distinct  symjjtoms  are  rare. 
In  a  series  of  20,000  consecutive  deliveries  at  the  Sloane  Hospital  there 
were  recorded  113  cases  of  hydramnios,  or  a  frequency  of  1  in  177. 

It  is  more  common  in  multigravida?  than  in  primigravida^.  In  this 
series  of  113  cases,  81  were  multigravidie  and  32  primigravida".     It  is 


DISEASES  OF  THE  AMNION  501 

more  common  in  multiple  than  in  single  pregnancy,  thus  in  this  series 
of  113  cases  there  were  23  women  with  multiple  pregnancy:  20  sets  of 
twins  and  3  sets  of  triplets.  This  of  course  is  a  much  greater  frequency 
than  is  normal  for  multiple  pregnancy. 

Etiology. — Although  the  exact  etiology  is  more  or  less  obscure,  three 
general  sources  are  usually  accepted  as  possible.  Thus  the  source  of  the 
fluid  may  be  (1)  fetal,  (2)  maternal,  (3)  amniotic. 

Fetal  Sources.— The  conditions  of  the  fetus  which  furnish  the  most 
satisfactory  explanation  of  the  excessive  amount  of  liquor  amnii  are 
lesions  in  the  umbilical  cord  or  in  the  fetus  itself,  causing  obstruction  to 
the  return  flow  of  blood  with  increased  blood-pressure  in  the  umbilical 
vein.  The  lesion  in  the  cord  may  be  an  obstruction  due  to  a  tight  knot 
or  the  pressure  of  a  tumor,  etc.  The  cause  of  the  obstruction  on  the  other 
hand  may  be  within  the  fetus  and  may  consist  of  a  cirrhosis  or  syphilitic 
disease  of  the  liver.  Not  infrequently  the  obstruction  to  the  circulation 
is  due  to  some  abnormality  of  the  fetal  heart.  If  for  any  reason  there  is 
some  obstruction  to  the  circulation  in  the  placenta  there  naturally 
results  an  hypertrophy  of  the  heart  and  for  a  time  it  may  be  equal  to 
the  task  required  of  it.  Later  on  it  becomes  insufficient;  an  edema  of 
the  placenta  and  an  increase  of  the  liquor  amnii  may  follow.  A  heart 
with  a  congenital  malformation  still  more  readily  becomes  unequal  to 
its  task  and  congestion,  edema  and  transudation  naturally  follow.  Under 
normal  conditions  the  fetal  kidneys  are  regarded  as  taking  little  part  in 
the  production  of  the  liquor  amnii.  When,  however,  the  fetal  heart 
becomes  hypertrophied,  more  fluid  is  forced  through  the  kidneys;  a 
greater  urinary  secretion  is  produced  and  in  some  cases  at  least  this 
increased  urinary  secretion  seems  a  marked  factor  in  the  production  of 
the  hydramnios.  This  method  of  production  of  hydramnios  seems  to 
find  its  illustration  in  certain  cases  of  uniovular  twins  in  which  one  of 
the  amniotic  sacs  is  in  the  condition  of  hydramnios.  Autopsy  on  the 
affected  twin  in  several  instances  of  this  complication  has  shown  an  hyper- 
trophy of  both  heart  and  kidneys  as  though  one  fetus  receiving  more 
blood  than  the  other  had  thrown  more  work  on  the  heart,  which  became 
hypertrophied  and  forced  more  blood  through  the  kidneys.  The  heart 
later  became  unequal  to  its  task  and  congestion  followed.  This  con- 
dition has  been  carefully  studied  by  Schatz,^  Wilson,^  ^Yerth■■^  and  others. 
The  amount  of  liquor  amnii  surrounding  the  other  fetus  may  be  either 
normal  or  diminished  in  amount.  In  quite  a  large  percentage  of  cases, 
fetal  deformities  such  as  spina  bifida,  anencephalous  monster,  hare-lip, 
exstrophy  of  the  bladder,  the  different  varieties  of  talipes,  etc.,  are  found 
associated  with  hydramnios.  An  excessive  cutaneous  transudation  of 
fluid  associated  with  cardiac  hypertrophy  in  the  fetus  has  been  looked 
upon  as  an  occasional  etiological  factor. 

1  Eine    besondere   Art  von   einseitiger  Polyhydramnie,   etc.,  Archiv  f.   Gyn.,    1882,   xix, 
329-369. 

2  Hydramnion  in  Cases  of  Uni  Oval,  or  Homologous  Twins,  Trans.  London  Obstet.  Soc, 
1899,  xli,  235-272. 

3  Einseitiges  Hj'dramnion  mit  Oligohydramnie  der  zweiten  Frucht,  Archiv  f.  Gyn.,  1882, 
XX,  353-377. 


502  DISEASES  OF  THE  FETAL  MEMBRANES 

Maternal  Sources. — In  a  few  cases  lesions  of  the  maternal  heart,  liver 
or  kidneys  with  evidences  of  obstruction  in  the  maternal  circulation 
are  associated  in  such  a  way  with  hydramnios  as  to  appear  to  be  related 
as  cause  and  effect. 

Amniotic  Source.— In  some  rare  cases  an  actual  inflammation  of  the 
amnion  seems  to  exist  which  causes  an  increased  secretion,  resulting  in 
hydramnios. 

Symptoms. — The  symptoms  arising  from  hydramnios  are  largely 
mechanical,  resulting  from  the  abnormal  intra-abdominal  pressure. 
These  symptoms  vary  of  course,  according  to  whether  the  hydramnios 
is  acute  or  chronic.  In  the  chronic  form,  which  is  much  more  common 
than  the  acute,  the  symptoms  closely  resemble  those  of  multiple  preg- 
nancy. There  is  more  tendency  to  edema  of  the  lower  extremities  and 
the  vulva  than  is  normal;  more  tendency  to  renal  disturbance;  more 
dyspnea  and  gastric  disturbance.  If  this  increase  in  pressure,  however, 
has  taken  place  gradually,  the  system  seems  to  be  able  to  accommodate 
itself  to  it  so  that  the  patient  may  be  able  to  go  to  term  without  an  extreme 
degree  of  suffering.  In  the  acute  hydramnios,  on  the  other  hand,  the 
picture  is  different.  Beginning  usually  between  the  fourth  and  the  sixth 
month  the  uterus  distends  rapidly.  The  uterine  and  abdominal  walls 
soon  become  tense  and  tender.  The  patient  in  well-marked  cases  suffers 
with  dyspnea,  perhaps  cyanosis.  She  may  have  to  sleep  bolstered  up 
in  bed,  gastric  digestion  is  often  mechanically  interfered  with,  and  her 
heart  becomes  overburdened.  The  lower  extremities  and  perhaps  the 
vulva  become  edematous.  The  kidneys  often  become  involved  and  in 
not  a  few  cases,  unless  nature  interi;"upts  the  pregnancy,  this  interruption 
has  to  be  brought  about  by  the  obstetrician  in  order  to  save  the  life  of 
the  woman.  Owing  to  the  amount  of  distention  of  the  uterus  and  the 
tenseness  of  the  uterine  and  abdominal  walls  it  is  often  impossible  to 
accurately  map  out  the  fetus,  and  it  is  often  difficult  to  hear  the  fetal 
heart  or  hearts,  hence  it  is  not  an  unusual  surprise  at  the  delivery  to 
fiiid  a  twin  pregnancy.  The  fetus  in  these  cases  is  usually  poorly  nour- 
ished and,  as  stated  above,  it  not  infrequently  presents  some  malforma- 
tion, hence  its  loss  if  pregnancy  has  to  be  interrupted  early  in  order  to 
save  the  mother  is  not  so  great. 

Diagnosis. — The  condition  from  which  hydramnios  most  often  has  to 
be  diagnosed  is  multiple  pregnancy.  If  these  two  conditions  exist  inde- 
pendently and  present  their  typical  signs  and  symptoms  the  diagnosis 
is  usually  easy.  The  hydramnios  presents  the  tense,  distended  uterus 
and  abdominal  wall  with  its  accompanying  dyspnea  and  pressure  symp- 
toms with  indistinct  fetal  parts  and  heart  sounds.  The  multiple  preg- 
nancy, on  the  other  hand,  presents  its  multiple  fetal  extremities  and  its 
multiple  heart  sounds  with  less  dyspnea  and  less  edema  or  other  pressure 
symptoms  because  the  growth  of  the  abdominal  tumor  has  been  more 
gradual  and  the  system  has  had  opportunity  to  adjust  itself  to  the 
increased  pressure.  The  difficulty  in  diagnosis  lies  in  the  fact  that  mul- 
tiple pregnancy  is  often  associated  with  hydramnios,  and  with  the  tense 
uterine  wall  of  hydramnios  in  many  cases  it  is  impossible  to  determine 


DISEASES  OF  THE  AMNION  503 

multiple  fetal  parts  or  fetal  hearts,  and  accurate  diagnosis  becomes  almost 
impossible.  In  a  few  cases  it  is  necessary  to  differentiate  between  hydram- 
nios  and  extra-uterine  abdominal  fluid,  encysted  or  free.  In  general  the 
diagnosis  is  made  by  first  determining  the  presence  or  absence  of  preg- 
nancy and  for  this  the  consideration  of  the  menstrual  history;  the  con- 
dition of  the  breasts;  the  appearance  of  the  vagina  and  cervix;  the  feel 
of  the  cervix  and  lower  uterine  segment;  the  shape  of  the  abdominal 
tumor  as  determined  by  a  bimanual  examination  and  the  presence  or 
absence  of  the  positive  signs  of  pregnancy  usually  answers.  If  the  exist- 
ence of  pregnancy  is  once  determined  it  is  usually  easy  to  differentiate 
hydramnios  from  extra-uterine  collections  of  fluid.  Occasionalh',  how- 
ever, pregnancy  coexists  with  ascites  or  a  large  ovarian  cyst,  which  may 
severely  tax  the  diagnostic  powers  of  the  obstetrician.  However,  the 
effect  of  position  in  changing  the  percussion  note  in  ascites  and  a  careful 
study  of  the  relation  of  the  ovarian  cyst  to  the  uterine  body  will  usually 
enable  him  to  arrive  at  a  correct  diagnosis. 

Treatment. — In  the  chronic  form  of  hydramnios  it  is  seldom  that 
active  treatment  is  indicated.  Realizing  the  excessive  intra-abdominal 
pressure,  the  patient  should  be  kept  quiet  and  elimination  should  be 
favored;  the  stomach,  liver  and  kidneys  should  be  taxed  as  little  as 
possible  by  restricting  nitrogenous  diet  and  giving  small  quantities  at 
shorter  intervals  than  usual.  The  author  has  never  been  able  to  accom- 
plish enough  in  withholding  such  fluid  as  the  patient  wishes  to  quench 
her  thirst  to  make  it  worth  while.  The  obstetrician  should  be  con- 
stantly on  the  alert  for  renal  complications. 

In  the  acute  hydramnios  with  marked  dyspnea  and  serious  embarrass- 
ment of  circulation  the  interruption  of  the  pregnancy  is  indicated, 
whatever  its  stage.  As  already  stated,  this  interruption  often  takes 
place  spontaneously,  but  if  not,  labor  should  be  induced.  On  account 
of  the  risk  of  the  sudden  gush  of  the  liquor  amnii  causing  prolapse  of  the 
cord  and  malpresentation  of  the  child,  and  the  sudden  emptying  of  the 
uterus  predisposing  to  postpartum  hem^orrhage,  the  membranes  should 
be  punctured  through  the  cervical  canal  and  the  liquor  amnii  be  allowed 
to  drain  off  slowdy. 

Prognosis. — In  chronic  hydramnios  the  prognosis  for  both  mother  and 
child  is  usually  good  under  careful  observation. 

In  acute  hydramnios  the  prognosis  for  the  mother  is  usually  good, 
provided  she  is  not  suffering  from  a  severe  constitutional  disease  and 
provided  she  is  carefully  watched  and  the  pregnancy  is  interrupted  before 
the  pressure  becomes  too  great.  The  prognosis  for  the  child  in  acute 
hydramnios  is  always  uncertain  for  the  reason  that  it  is  often  premature, 
usually  poorly  nourished,  and  not  infrequently  malformed. 

Oligohydramnios. — ^In  a  few  rare  cases  the  liquor  amnii  instead  of 
being  abnormally  increased  in  amount  is  abnormally  decreased,  so  that 
the  fluid  surrounding  the  fetus  is  insufficient  for  its  protection  and 
development.  This  is  called  oligohydramnios .  Most  authorities  state 
its  frequency  as  about  once  in  four  thousand  cases.  It  is  met  with  not 
only  in  single  uterine  pregnancies,  but  in  multiple  pregnancies  and  in 


504 


DISEASES  OF   THE  FETAL  MEMBRANES 


advanced  cases  of  ectopic  gestation.  Little  is  known  of  the  etiology  of 
the  condition.  In  a  case  reported  by  Strassmann,*  in  1894,  there  was 
an  absence  of  both  kidneys,  and  in  a  case  reported  by  Jagcrard,'-  in  the 
same  year,  there  was  an  absence  of  one  kidney  and  a  cystic  degeneration 
of  the  other.  These  cases  suggest  the  possibility  of  the  absence  of  kidney 
function  being  the  cause  of  the  oligohydramnios  in  some  cases.  The 
presence  of  this  etiological  factor,  however,  is  by  no  means  uniform.  In 
some  cases  of  oligohydramnios  the  fetal  skin  has  been  found  thick  and 
dry,  with  very  little  secretion,  but  whether  this  was  the  result  or  one  of 


Fig.  318. — Intra-uterine  amputation,  healed  at  hirth. 

the  causes  of  the  oligohydramnios,  has  never  been  settled.  The  results 
of  oligohydramnios  are  most  serious  when  it  occurs  in  the  early  part  of 
pregnancy,  as  with  insufficient  fluid  to  separate  the  amnion  from  the 
fetus,  adhesions  form  between  the  two  and  numerous  fetal  malformations 
occur.  Faults  of  fusion  in  the  midline,  different  forms  of  talipes,  intra- 
uterine amputations  by  the  bands  of  adhesions,  interference  with  the 
nutrition  and  distortion  of  the  fetus  from  pressure  are  among  the  results 

'  Zeitschrift  f.  Geburtsh.  u.  Gynak..  1894,  Band  xx\-iii,  Heft  1,  181. 
-  Amer.  Jour.  Obstet.,  1894,  xxix,  432-446. 


DISEASES  OF   THE  AMNION  505 

found  in  oligohydramnios.  In  some  cases  the  fetal  circulation  is  so 
interfered  with  as  to  kill  the  fetus  and  cause  its  expulsion.  In  some 
cases  of  twin  pregnancy  one  amniotic  sac  has  an  abundance,  perhaps 
even  an  excess,  of  liquor  amnii,  while  the  other  sac  has  hardly  any,  and 
the  fetus  in  this  sac  is  malformed,  perhaps  even  compressed  to  a  fetus 
papyraceous.  Oligohydramnios  occurring  late  in  pregnancy  is  usually 
less  disastrous  than  when  it  occurs  early,  but  even  here  abnormal  compres- 
sion and  various  minor  deformities  are  often  seen.  The  same  may  be 
said  regarding  advanced  cases  of  ectopic  gestation  where  there  is  little 
fluid  in  the  amniotic  sac. 

Intra-uterine  Amputations. — Intra-uterine  amputations  have  already 
been  referred  to.  It  is  readily  understood  that  the  amniotic  bands  of 
adhesion,  by  encircling  any  portion  of  the  upper  or  lower  extremities, 
may,  by  interfering  with  its  circulation,  cause  sloughing  and  even  ampu- 
tation. Children  are  occasionally  born  in  w^hich  such  an  amputation 
has  occurred  from  this  cause  and  the  stump  has  healed  (Fig.  318).  Not 
infrequently  the  delivery  is  premature,  but  if  the  pregnancy  goes  to  term 
and  firm  adhesions  have  formed  between  the  placenta  and  the  fetus, 
the  labor  is  apt  to  be  tedious  and  distressing  and  there  is  always  the 
risk  of  a  premature  separation  of  the  placenta  with  danger  alike  to 
mother  and  child. 


CHAPTER  XV. 
ABORTION. 

The  arrest  of  gestation  and  expnlsion  of  the  ovum  prior  to  the  period 
of  viability  of  the  child  is  called  by  the  medical  profession  abortion. 

This  term,  however,  has  been  so  long  associated  with  the  criminal 
operation  that  it  is  distasteful  to  patients,  who  speak  of  the  occurrence 
as  a  miscarriage,  and  it  is  always  wise  for  the  physician  in  the  presence 
of  his  patient  to  use  this  latter  expression. 

The  twenty-eighth  week  or  the  completion  of  the  seventh  month  of 
gestation  is  generally  accepted  as  the  period  of  viability,  for  although 
by  means  of  an  incubator  the  life  of  a  child  of  less  than  seven  months' 
gestation  has  occasionally  been  saved,  this  result  is  so  exceptional  that 
it  is  not  to  be  expected  and  little  hope  of  it  should  be  given.  Interrup- 
tion of  pregnancy  then,  prior  to  the  completion  of  the  seventh  month, 
may  be  called  abortion  or  miscarriage,  and  between  the  seventh  month 
and  term,  premature  labor. 

Frequency. — In  1000  consecutive  patients  in  the  author's  private  prac- 
tice who  have  been  pregnant,  371  have  had  one  or  more  miscarriages. 
This  shows  the  extreme  frequency  of  the  occurrence,  i.  e.,  a  little  more 
often  than  1  in  3  (although  it  is  impossible  to  tell  how  many  of  these 
were  induced).    In  this  1000  cases  53  miscarried  in  their  first  pregnancy. 

Etiology. — In  studying  the  etiology  of  abortion  the  following  factors 
may  be  recognized:  (a)  Traumatism,  (6)  maternal  causes,  (c)  fetal 
causes,  (d)  paternal  causes. 

A.  Traumatism. — Under  this  heading  may  be  placed  all  forms  of 
violence,  as  blows,  falls,  lifting  heavy  weights,  excessive  action  of  the 
abdominal  muscles,  as  in  severe  vomiting,  coughing  or  sneezing,  exces- 
sive or  violent  intercourse,  the  introduction  of  instruments,  etc.  All 
these  probably  act  by  causing  hemorrhage  into  the  decidua  or  between 
the  decidua  and  the  uterine  wall  thus  separating  more  or  less  of  the  ovum 
from  its  attachment. 

B.  Maternal  Causes. — Here  may  be  mentioned: 

1.  Causes  acting  through  the  nervous  system,  as  mental  shock;  reflex 
irritation,  as  from  nursing  a  child  while  again  pregnant;  nervous  diseases, 
as  chorea,  epilepsy,  etc. 

2.  Causes  Acting  through  the  Blood. — One  of  the  most  frequent 
causes  of  abortion  is  a  condition  or  group  of  conditions  in  the  mother 
which  is  called  a  toxemia.  The  nature  of  this  toxemia  is  not  known 
at  present,  and  it  can  only  be  said  that  products  of  metabolism  which 
should  be  oxidized,  rendered  innocuous-  and  eliminated,  probably  cir- 
culate in  the  blood  in  a  harmful  form. 

(506) 


ETIOLOGY  OF  ABORTION  507 

Also  acting  through  the  blood  of  the  mother  is  syphilis  with  its  accom- 
panying disease  of  the  decidua,  and  this  disease  should  always  be  thought 
of  in  searching  for  the  etiology  of  repeated  miscarriages  in  a  given  case. 

High  fevers^  especially  with  a  temperature  above  105°  F.,  predispose 
to  a  miscarriage.  This  is  often  seen  in  typhoid  fever  through  which,  if 
the  course  is  a  mild  one  and  the  temperature  relatively  low,  the  preg- 
nant patient  will  often  pass  without  interruption  of  the  pregnancy,  while 
on  the  other  hand,  if  the  course  is  severe  and  the  temperature  high, 
abortion  is  common. 

Malarial  fever  also  predisposes  to  abortion,  and  in  all  probability  some 
of  the  cases  of  abortion  assigned  to  the  administration  of  quinine  have 
been  due  to  the  malarial  infection  for  which  the  quinine  was  given. 

Acting  through  the  blood  of  the  mother  as  causes  of  abortion  may 
also  be  mentioned  poisonous  drugs,  as  mercury,  phosphorous,  lead,  ergot, 
etc.;  poisonous  gases,  as  coal  gas,  or  a  lack  of  elimination  of  carbon 
dioxide  gas,  in  diseased  conditions  of  the  heart  and  lungs,  and  lastly,  an 
impoverished  condition  of  the  blood  itself  as  in  extreme  anemia,  will 
sometimes  produce  an  abortion. 

.3.  Local  Causes. — Probably  the  most  common  cause  of  abortion  or 
miscarriage  is  an  endometritis  which  interferes  with  the  formation  of  a 
healthy  decidua  and  normal  attachment  of  the  ovum.  The  causes  of  the 
endometritis  may  be  varied,  but  it  is  the  endometritis  itself  which  stands 
in  direct  etiological  relation  with  the  separation  of  the  ovum. 

A  posterior  displacement  of  the  uterus  is  one  of  the  common  causes  of 
abortion  and  in  the  judgment  of  the  author  this  forms  the  chief  argument 
in  favor  of  bimanual  examination  of  a  patient  early  in  pregnancy.  The 
displacement  may  cause  the  abortion  in  one  of  two  ways :  either  through 
the  endometritis  resulting  from  the  chronic  congestion  produced  by  the 
retroversion  or  retroflexion,  or  if  the  uterus  is  fixed  by  adhesions  and 
incarcerated  beneath  the  promontory  of  the  sacrum,  as  the  growth  con- 
tinues something  has  to  give  way  and  the  uterus  relieves  its  tension  by 
emptying  itself  in  the  direction  of  least  resistance,  i.  e.,  through  the 
cervical  canal. 

Abortion  is  sometimes  produced  by  adhesions  outside  of  the  uterus 
interfering  with  its  normal  expansion;  by  lacerations  of  the  cervix,  which 
give  too  little  support  at  the  outlet  of  the  uterus  and  also  expose  it  to 
constant  irritation  and  perhaps  endometritis. 

Tumors  of  the  uterus,  especially  fibromyomata,  will  sometimes  cause 
an  abortion,  although  many  times  a  patient,  whose  uterus  is  studded 
with  fibroids,  will  pass  through  pregnancy  without  the  slightest  tendency 
to  abort. 

When  abortion  is  produced  by  a  fibromyoma  it  is  probably  caused 
either  by  the  encroachment  of  the  tumor  upon  the  cavity  of  the  uterus 
or  by  the  endometritis  which  accompanies  it. 

In  placenta  previa  abortion  and  premature  labor  are  well  known  to  be 
common.  -    .« 

C.  Fetal  Causes. — Under  thi?  heading  may  be  grouped  any  disease 
of  the  fetus  or  fetal  membranes  destroving  the  life  of  the  fetus.    While 


508  ABORTION 

a  dead  fetus  may  sometimes  be  retained  within  the  cavity  of  the  uterus 
for  weeks,  months,  or  even  years,  as  a  rule  the  uterus  soon  regards  it  as 
a  foreign  body  and  expels  it  in  from  one  to  four  weeks.  Among  the 
causes  of  fetal  death  may  be  mentioned  hemorrhage  into  the  placenta, 
degeneration  of  the  chorion,  extreme  torsion  of  the  cord  with  stenosis 
of  its  vessels,  etc. 

D.  Paternal  Causes. — The  one  chief  cause  of  abortion  assignable  to 
the  father  is  syphilis,  producing  from  syphilitic  spermatozoa  syphilitic 
changes  in  the  placenta  and  fetus.  In  addition  to  syphilis,  constitutional 
exhaustion  from  alcoholic  or  venereal  excesses,  from  tuberculosis  or 
other  wasting  diseases,  by  producing  unhealthy  spermatozoa  seems  to 
predispose  to  abortion. 

The  occurrence  of  an  abortion  often  seems  in  itself  a  predisposing 
cause  of  a  recurrence. 

The  above-mentioned  causes,  save  traumatism,  are  largely  predisposing 
in  character,  and  with  one  or  more  of  these  predisposing  causes  present 
it  is  evident  that  a  very  slight  traumatism  might  serve  as  an  exciting 
cause.  Classified  according  to  etiology,  abortion  may  be  looked  upon 
as  either  accidental  or  intentional,  these  terms  being  self-explanatory. 
Intentional  abortion  may  be  either  criminal  or  medical,  the  latter 
expression  being  used  to  cover  those  interruptions  of  pregnancy  which 
are  demanded  for  the  life  and  health  of  the  mother  and  which  are  per- 
formed by  the  medical  attendant  after  careful  and  conscientious  study 
of  the  case. 

Symptoms. — Classified  according  to  symptoms,  abortion  may  be  either 
threatened  or  inevitable.  The  symptoms  of  threatened  abortion  are 
hemorrhage  and  perhaps  pain.  Usually  the  first  evidence  of  any  tendency 
to  abort  or  miscarry  is  a  bloody  discharge  from  the  vagina.  This  may 
be  accompanied  or  soon  followed  by  slight  recurring  pains.  However,  a 
woman  may  have  a  slight  bloody  flow  for  a  number  of  days  and  with  it 
occasional  recurrent  pains  which  under  proper  treatment  may  subside, 
the  patient  go  to  term  and  be  delivered  of  a  healthy  child.  These  symp- 
toms then  (hemorrhage  and  pain)  may  be  only  those  of  a  threatened 
abortion,  but  if  in  addition  to  the  hemorrhage  and  pain  there  is  found 
on  examination  a  dilatation  of  the  cervix  and  a  beginning  protrusion  of 
the  ovum  the  abortion  becomes  inevitable.  There  may  also  be  certain 
prodromal  symptoms  of  general  malaise  and  increase  in  the  vaginal 
mucus,  and  an  increased  frequency  of  micturation. 

Pathology. — Whatever  the  etiology  of  an  abortion  the  pathological 
result  is  usually  an  effusion  of  more  or  less  blood  into  the  decidua  or 
between  the  decidua  and  the  uterine  wall  (see  Plate  VII).  In  a  threat- 
ened abortion  (Plate  VII,  Fig.  1)  this  may  be  slight  and  not  enough  to 
separate  any  material  portion  of  the  chorion  or  placenta  from  the  uterine 
wall.  In  an  inevitable  abortion,  on  the  other  hand  (Plate  VII,  Fig.  2), 
more  and  more  of  the  ovum  is  separated  until,  under  the  influence  of  the 
uterine  contractions,  either  the  entire  ovum  is  expelled  from  the  uterus 
as  in  complete  abortion  (see  Fig.  319),  or  the  embryo  is  expelled,  leaving 
behind  more  or  less  of  its  membranes  and  the  decidua  as  in  an  incomplete 


PLATE  VII 


FIO.   1 


Threatened  Abortion. 

FIG.   2 


Inevitable  Abortion. 


PATHOLOGY  OF  ABORTION 


509 


abortion,  or  the  entire  ovum  is  retained  for  a  time  within  the  cavity  of 

the  uterus  as  a  mole.  ,       .       .  ;  ^      u      4.u 

Classified  according  to  pathology  then,  abortion  is  comvlete  when  the 
entire  ovum  is  expelled  from  the  uterus;  incomplete,  when  a  part  ot  the 
ovum  is  retained. 


Fig.  319. — Complete  abortion. 

In  a  complete  abortion,  which  takes  place  soon  after  the  occurrence 
of  the  hemorrhage  and  uterine  contractions  which  caused  its  separation, 
the  embryo  will  be  found  enclosed  in  its  sac  of  amnion  and  chorion  with 
the  luxuriant  chorionic  villi  surrounded  by  more  or  less  of  the  decidua  and 
covered  with  more  or  less  blood.  In  some  early  cases,  as  in  Fig.  319,  the 
ovum  is  enclosed  in  a  practically  complete  triangular  decidual  sac  In 
this  case  the  patient,  a  private  patient  of  the  author's,  menstruated  last 


510 


ABORTION 


on  October  5,  1900,  and  the  ovum  in  the  deci(kial  sac  was  discharged 
December  17,  1900. 

Often  in  a  practically  complete  abortion  a  little  of  the  decidiia  is  left 
behind,  as  often  occurs  in  a  normal  labor  at  term,  but  as  it  usually  comes 
away  in  the  lochia  without  symptoms,  the  retention  of  only  a  little  decidua 
and  nothing  else  is  usually  not  regarded  sufficient  to  place  it  in  the  class 
of  incomplete  abortion. 


Fig.  320. — Fetus  only  expelled;  membranes  retained. 


In  the  incomplete  abortion  the  fetus  alone  may  be  expelled  and  the 
membranes,  amnion,  chorion  and  decidua  all  be  retained,  as  in  Fig.  320, 
or  especially  in  early  abortions  the  ovum  may  be  covered  only  by  amnion 
(Fig.  321),  or  by  amnion  and  chorion  with  its  luxuriant  villi,  so  that 
the  specimen  obtained  may  be  a  little  vesicle  covered  with  the  shaggy 
chorionic  villi  (see  Fig.  322). 

In  quite  a  large  percentage  of  cases  the  ovum  is  retained  within  the 
uterus  for  a  considerable  time  after  the  death  of  the  fetus.  Under  these 
circumstances  the  blood  effusion  which  havS  gradually  surrounded  the 


PATHOLOGY  OF  ABORTION 


511 


ovum  coagulates  and  there  is  formed  a  blood-clot  whose  centre  consists 
of  a  more  or  less  degenerate  ovum.  This  structure  is  spoken  of  as  a  mole 
and  is  called  a  sanguineous  or  bloody  mole,  when  the  encapsulating  blood- 
clot  is  relatively  fresh  and  retains  its  blood-red  color  (see  Fig.  323),  and 
a  carneous  or  fleshy  vwle,  when  from  the  deposit  of  fibrin  the  encapsu- 


FiG.  321. — Fetus  covered  only  with  amnion. 


lating  blood-clot  has  lost   its  original  appearance  and  consistency  and 
has  become  more  fleshy  in  character. 

If  a  section  is  made  through  one  of  these  moles  after  its  discharge  from 
the  uterus  there  is  usually  found  in  its  centre  a  small  cavity  lined  with  a 
smooth  membrane  (the  amnion)  and,  depending  upon  the  development 


512 


ABORTION 


of  the  ovum  and  the  age  of  the  mole,  there  may  be  found  liangin<i;  from 
one  point  of  the  membrane  either  a  small  umbilieal  cord  and  partially 
degenerated  fetus  or  perhaps  only  a  remnant  of  an  umbilical  cord,  the 
fetus  having  been  absorbed. 

In  all  moles  the  fetus  is  smaller  than  would  be  expected  from  the 
menstrual  history,  showing  that  the  death  of  the  fetus  occurred  a  con- 
siderable time  before  its  expulsion  from  the  uterus. 


Fig.  322. — Ovum  with  amnion  and  chorion  expelled. 


A  complete  absorption  of  the  fetus  can  only  take  place  in  the  early 
weeks  of  development.  If  it  is  retained  in  the  uterus  after  it  has  reached 
any  considerable  size  it  usually  macerates  and  decomposes,  becoming  a 
serious  menace  to  maternal  life.  Rarely,  however,  it  undergoes  a  drying 
process  called  mummificaiion.  In  twin  pregnancy  one  of  the  twins 
sometimes  thrives  at  the  expense  of  the  other  and  the  unfortunate  twin 
becomes  compressed  and  thinned  out  and  is  only  found  at  term  as  a 
fetus  papyraceous  or  parchment-like  fetus  (see  Fig.  324),  in  the  mem- 
brane of  what  might  at  first  be  thought  a  single  pregnancy. 


TREATMENT  OF  ABORTION 


513 


Very  rarely  in  intra-uterine  pregnancy,  but  much  more  often  in  ectopic 
gestation,  a  fetus  is  retained  until  it  is  converted  by  the  deposition  of 
lime  salts  into  a  relatively  innocuous  litJwpedion. 

Treatment. — Prophylaxis. — The  most  important  factor  in  the  prophyl- 
actic treatment  of  abortion  is  the  education  of  patients  in  the  moral 
and  legal  wTong  as  well  as  the  danger  of  induced  abortion.  Many  women, 
remarkably  conscientious  in  perhaps  almost  every  other  action,  seem  to 
lose  all  sense  of  right  and  wrong  when  possessed  of  the  desire  to  rid  them- 
selves of  the  product  of  conception.  They  vrill  often  state  that  all  their 
friends  get  relief  and  they  are  going  to  have  it.    ]Many  satisfy  themselves 


Fig.  323. — Sanguineous  mole. 


with  the  idea  that  very  early  in  pregnancy  there  is  little  form  to  the 
ovum  and  it  amounts  to  nothing.  There  are  two  good  methods  of  edu- 
cation of  the  laity  in  this  matter — one  is  to  show  them  either  a  specimen 
or  a  photograph  of  a  fetus  of  two  or  three  months'  development  and  to 
tell  them  that  there  is  certainly  life  in  the  fetus  and  that  the  destruction 
of  that  life  is  a  crime,  both  morally  and  legally,  just  as  the  taking  of  the 
life  of  the  child  a  year  after  it  is  born  would  be  a  crime.  ]Many  a  woman, 
when  this  phase  of  the  subject  has  been  presented  to  her,  has  been 
persuaded  to  abandon  her  determination  to  terminate  her  pregnancy. 
Another  method  which  is  often  useful  is  to  instruct  the  patient  in  the 
33 


514 


ABORTION 


dangers  of  induced  abortion  and  to  assure  her  that  no  reputable  member 
of  the  profession  will  have  anything  to  do  with  carrying  out  her  desire 
and  that  she  cannot  afford  to  risk  her  life  in  the  hands  of  disreputable 
men  whose  hands  and  instruments  would,  like  their  work,  probably  be 
unclean. 

The  education  of  patients  along  these  two  lines  of  moral  responsibility 
and  dangers  of  induced  abortion  has  saved  the  life  of  many  an  unborn 
fetus. 


Fig.  324. — Fetus  papyraceous  in  membranes  of  full-term  fetus. 


Unfortunately  for  the  unborn  race,  some  of  the  modern  abortionists 
have  learned  to  do  the  criminal  act  in  the  same  aseptic,  scientific  manner 
which  is  employed  by  the  conscientious  surgeon  when  the  uterus  has  to 
be  emptied  in  orfler  to  save  the  life  of  the  mother,  in  this  way  making 
detection  of  the  abortionists'  crime  more  difficult. 

Before  leaving  the  subject  of  the  prophylactic  treatment  of  abortion 
it  is  fitting  that  something  be  said  regarding  the  position  of  the  physician 
toward  the  persuasion  of  his  patients  to  interrui:)t  their  pregnancy  for 
other  than  medical  reasons.  I  will  not  call  it  a  temjjtation,  as  no  man 
should  allow  the  persuasion  to  so  influence  him  as  to  become  a  temptation. 


PLATE   VIII 


Vagina  and  Cervical  Canal  Packed  with  Gauze. 


TREATMENT  OF  ABORTION  515 

Many  a  case  will  present  itself  which  will  arouse  his  sympathies  and 
make  him  wish  with  all  his  heart  that  his  patient  had  not  become  pregnant 
at  just  this  apparently  the  most  inopportune  time  for  her,  but  there  is 
only  one  position  for  the  reputable  conscientious  physician  to  take,  i.  e., 
that  save  for  distinct  medical  reasons  with  which  a  fellow  practitioner 
concurs,  he  will  have  nothing  to  do  with  the  induction  of  abortion,  even 
if  the  patient  making  the  plea  is  the  wealthiest  and  most  influential  in 
his  practice. 

Treatment  of  Threatened  Abortion. — On  the  occurrence  of  any  uterine 
hemorrhage  with  or  without  pain  the  patient  should  be  at  once  put  to 
bed,  her  mental  excitement  quieted  as  much  as  possible  by  words  of 
encouragement  and  her  uterine  irritability  quieted  by  an  opiate.  In 
order  to  get  a  rapid  effect  the  author's  custom  is  to  first  administer 
a  hypodermic  injection  of  morphin  (gr.  \-\)  and  then  continue  the 
influence  of  the  opiate  by  giving  codein  (gr.  ss)  every  two  hours  for 
two  or  three  doses.  If  no  pain  appears  the  codein  can  then  be  dis- 
continued, only  to  be  resumed  at  intervals  of  about  four  hours  if  pain 
recurs.  The  patient  should  lie  quietly  on  the  back  and  should  receive 
only  light,  non-stimulating  nourishment,  better  cool  than  hot.  The 
application  of  an  ice-bag  just  above  the  symphysis  often  quiets  uterine 
irritability.  After  a  day  or  two  if  neither  pain  nor  hemorrhage  recurs 
the  fluidextract  of  viburnum  may  be  substituted  for  the  opiate,  but  the 
patient  should  be  kept  oiT  her  feet  for  a  number  of  days  after  all  hemor- 
rhage and  pain  have  ceased. 
^  Treatment  of  Inevitable  Abortion. — As  soon  as  it  is  evident  that  to  the 
symptoms  of  hemorrhage  and  pain,  which  may  belong  only  to  a  threat- 
ened abortion,  there  is  added  a  beginning  dilatation  of  the  cervix  and  a 
protrusion  of  the  ovum  into  the  cervical  canal,  the  picture  changes  from 
that  of  a  threatened  to  one  of  inevitable  abortion  and  the  object  then 
desired  is  the  speedy,  complete  emptying  of  the  uterus  with  as  little 
hemorrhage  and  pain  as  possible.  If  the  cervix  is  dilating  rapidly  and 
everything  progressing  favorably  the  best  treatment  is  to  leave  the 
patient  alone  and  allow  the  uterus  to  empty  itself  as  completely  as 
possible.  It  is  extremely  important,  however,  that  everything  passed 
from  the  vagina  should  be  preserved  for  careful  examination  to  deter- 
mine whether  or  not  the  ovum  has  been  completely  expelled.  Under 
two  months  the  ovum  is  often  so  completely  expelled  that  the  uterus 
may  be  considered  empty,  but  after  this  period  of  gestation  an  incomplete 
abortion  becomes  the  rule. 

If  the  cervix  is  slow  in  dilating  and  the  hemorrhage  is  profuse,  one  of 
the  best  methods  of  treatment  is  to  pack  the  cervical  canal  and  the 
vagina  with  a  long  strip  of  iodoform  gauze  (see  Plate  A^III).  This 
tends  to  check  the  hemorrhage  by  confining  it  between  the  decidua  and 
the  uterine  wall,  and  occurring  in  this  confined  space  the  hemorrhage 
tends  to  separate  the  ovum  more  and  more  completely  from  the  uterine 
wall  at  the  same  time  that  the  gauze  tends  to  soften  and  dilate  the  cer- 
vical canal.  Often,  if  the  gauze  is  removed  at  the  end  of  eight  to  twelve 
hours,  the  cervix  is  found  dilated  and  the  ovum  lying  free  in  the  canal. 


516  ABORTION 

If  the  cervix  is  well  dilated  or  easily  dilatable  and  the  ovum  is  not  steadily 
advancing,  the  discomfort  of  the  woman  and  the  amount  of  blood  loss 
may  be  markedly  lessened  by  putting  the  patient  under  an  anesthetic 
and  with  the  finger  or  fingers  of  the  sterile  gloved  hand  sweeping  around 
the  cavity  of  the  uterus  and  removing  the  ovum,  blood-clots,  etc.  After 
this  procedure  it  is  well  to  irrigate  the  cavity  of  the  uterus  with  some 
sterile  solution  like  normal  saline  solution  to  remove  all  debris  and  then 
follpw  it  with  an  intra-uterine  tamponade  of  a  weak  iodoform  or  bismuth 
gauze.  The  use  of  the  gauze  tamponade  has  the  advantage  not  only  of 
controlling  hemorrhage  but  in  the  withdrawal  of  the  gauze  the  uterine 
cavity  is  wiped  clean  of  retained  portions  of  decidua  if  there  be  any. 
Iodoform  or  bismuth  gauze  is  better  than  plain  gauze,  as  the  latter 
remains  sweet  in  the  uterus  but  a  short  time.  Attention  has  already  been 
called  to  the  fact  that  the  specimen  passed  from  the  uterus  should  be 
saved  and  carefully  examined  to  see  if  it  is  complete.  This  is  usually 
best  determined  by  floating  the  specimen  in  water.  It  is  exceptional 
that  the  ovum  is  cast  oflF  with  the  deciduse  complete,  as  shown  in  Fig.  319, 
and  especially  rare  is  this  occurrence  after  the  second  month.  Even  if 
the  amnion  and  chorion  are  complete  it  is  common  to  find  patches  of 
decidua  absent.  If  the  cast-off  ovum  is  surrounded  by  the  complete 
deciduse,  of  course  the  abortion  is  complete  and  no  intra-uterine  inter- 
ference is  indicated.  If  only  small  patches  of  decidua  parietalis  are  absent 
from  the  specimen  when  carefully  examined,  it  may  be  regarded  as  prac- 
tically complete  and  so  treated,  the  uterine  cavity  being  left  alone. 

Treatment  of  Incomplete  Abortion.- — The  question  now  arises,  What  is 
the  best  treatment  when  only  a  part  of  the  ovum  has  been  discharged, 
the  remainder  being  retained  within  the  cavity  of  the  uterus?  Often  it 
is  only  the  fetus  which  is  discharged,  the  amnion,  chorion  and  decidua 
being  retained. 

This  is  especially  common  in  and  after  the  third  month.  All  degrees 
of  incompleteness,  however,  occur — from  the  fetus  alone  to  the  fetus 
surrounded  by  the  amnion,  chorion  and  most  of  the  decidua.  The  earlier 
the  abortion,  the  more  likely  is  it  to  be  complete;  while  the  more  mature 
the  placenta,  the  more  likely  is  the  fetus  to  be  the  only  part  to  be  dis- 
charged. Even  in  the  early  weeks,  if  only  the  ovum  is  discharged  (see 
Fig.  322), enough  decidua  maybe  retained  to  cause  continued  hemorrhage. 

In  an  abortion  which  is  known  to  be  incomplete  there  is  only  one  rule 
which  should  be  followed  in  treatment:  The  uterus  should  be  emptied 
with  the  least  injury  and  with  the  greatest  cleanliness.  The  best  instrument 
for  emptying  a  uterus  when  the  cervix  is  well  dilated  or  easily  dilatable 
is  the  aseptic  finger  or  fingers.  If  one,  or  preferably  two,  fingers  can  be 
introduced  into  the  uterine  cavity,  with  the  assistance  of  the  other  hand 
on  the  abdomen  depressing  the  abdominal  and  uterine  walls  in  apposi- 
tion to  the  intra-uterine  fingers,  every  part  of  the  uterine  cavity  can  be 
palpated  and  the  presence  of  secundines  detected  and  removed.  The 
uterine  cavity  is  then  irrigated  to  wash  away  loosened  debris  and  the 
intra-uterine  tamponade  used.  There  are  many  incomplete  abortions, 
however,  in  which  the  cervical  canal  is  not  sufficiently  dilated  or  easily 


TREATMENT  OF  ABORTION 


517 


dilatable  to  admit  the  finger.  In  such  instances  some  substitute  for  the 
finger  must  be  used.  The  two  instruments*  which  in  the  author's  exper- 
ience have  proved  most  valuable  are  seen  in  Fig.  325.  A  blunt,  firm 
curette  and  a  sponge  holder.  The  loop  of  the  curette  is  flat  on  one  sur- 
face and  the  shank  is  rigid  enough  to  give  all  the  scraping  power  needed, 
while  the  loop  is  large  enough  to  make  perforation  of  the  uterus  unlikely. 
The  sponge  holder  is  made  with  halves  separable  so  that  one-half  may  be 
used  as  a  curette  if  desired.  The  general  plan  in  the  use  of  these  two 
instruments  is  to  separate  the  membranes  from  the  uterine  wall  with 


Fig.  325. — Sponge  holder  and  curette. 


the  curette  and  then  remove  them  from  the  uterine  cavity  with  the  sponge 
holder.  In  using  the  curette  but  little  force  should  be  employed  and  that 
little  should  be  in  the  direction  toward  the  operator,  the  instrument 
being  ver^  gently  introduced  until  the  fundus  of  the  uterus  is  reached 
and  then  all  scraping  done  in  the  withdrawal.  The  contact  of  the  curette 
with  the  fundus  is  more  easily  detected  if  the  latter  is  steadied  and  gently 
depressed  by  the  hands  of  an  assistant  or  nurse.  Each  side  and  cornu 
of  the  uterus  should  in  turn  be  gone  over  by  the  curette  but  always 
with  the  thought  of  doing  as  little  injury  as  possible  to  the  uterine  wall. 


518 


ABORTION 


111  onltT  to  use  tlu'  two  instruincnts  shown  above,  three  other  instriiiiients 
are  usually  needed  as  adjuvants  (see  Fig.  32(3). 

1.  A  volsella  to  hold  the  cervix. 

2.  A  perineal  retractor,  one  st\le  of  which  is  here  represented. 

3.  A  glove  stretcher  dilator. 

Following  the  use  of  the  curette  and  sjjonge  holder  some  sort  of  a 
iloul)le-current  catheter  is  needed  for  washing  away  debris,  and  for  this 


Fig.  .326. — Volsella,  perineal  retractor  and  dilator. 

purpose  the  Bozenian-Fritsch  instrument  shown  in  Fig.  327  answers 
well. 

If  an  intra-uterine  tamponade  is  indicated,  the  packing  forceps 
shown  in  Fig.  327  for  introducing  gauze  is  very  useful. 

The  advantage  gained  by  the  introduction  of  the  finger  or  fingers 
and  palpation  of  the  uterine  cavity  to  determine  that  it  is  empty  is  well 
illustrated  by  2  cases  which  have  come  under  the  author's  observation. 

In  the  first  case  the  uterus  was  carefully  curetted  after  an  incomplete 
abortion  and  was  supposed  to  be  left  empty.    On  about  the  tenth  day 


TREATMENT  OF  ABORTION 


519 


afterward  she  passed  the  whole  placenta  which  at  the  time  of  the  curet- 
tage had  been  firmly  adherent  to  the  uterine  wall  and  allowed  the  curette 
to  pass  over  its  amniotic  surface  and  escaped  detection.  A  finger  intro- 
duced into  the  cavity  of  the  uterus  would  certainly  have  not  allowed  this 
oversight. 

This  experience  occurred  early  in  the  professional  career  of  the  author 
and  taught  him  a  lesson  never  to  be  forgotten. 


Fig.  327. — Packing  forceps  and  double-current  catheter. 

The  second  case  was  sent  to  the  author's  hospital  ward  by  a  very  able 
practitioner  who  said  that  he  had  carefully  curetted  and  emptied  the 
uterus  but  that  the  woman  was  not  properly  situated  at  home  for  con- 
valescence and  requested  that  she  be  admitted  to  the  hospital  for  care 
during  her  recovery.  The  following  morning  she  passed  the  fetus 
enveloped  in  a  complete  amnion  and  chorion. 

The  fetus  in  its  sac  had  evidently  been  attached  to  the  fundus  of  the 
uterus  and  the  curette  had  passed  all  around  it  without  interfering  with 


520  ABORTION 

its  attachment.    A  finger  introduced  into  the  uterine  cavity  would  have 
detected  its  presence. 

The  question  arises:  What  should  be  done  if  the  obstetrician  is  called 
to  attend  a  case  of  abortion  in  which  the  patient  is  said  to  have  passed 
the  ovum  but  the  specimen  was  not  saved?  Two  alternatives  present 
themselves:  The  first  is  to  keep  the  patient  in  bed  and  await  develop- 
ments, and  consider  the  abortion  complete  if  all  bleeding  ceases  within 
a  week  and  no  rise  of  temperature  occurs.  The  second  is  to  consider  the 
abortion  incomplete  so  long  as  evidence  to  the  contrary  is  lacking  and 
treat  the  case  as  an  incomplete  abortion.  In  an  abortion  of  less  than 
two  months'  gestation  the  author  believes  the  first  alternative  good 
practice.  But  when  the  period  of  gestation  is  more  than  two  months, 
provided  the  dilatation  of  the  cervix  and  evidence  of  blood  lost  are 
sufficient  to  convince  him  that  the  abortion  was  certainly  of  the  inevit- 
able type,  he  believes  the  second  alternative  the  correct  .procedure  and 
that  the  patient  should  be  anesthetized,  her  uterus  explored  and  either 
demonstrated  to  be  empty  or  made  so  at  once. 

In  this  connection  it  may  be  well  to  caution  the  physician  not  to  be 
deceived  by  the  statements  of  women  anxious  to  have  abortion  per- 
formed. 

Treatment  of  Neglected  Abortion. — Under  this  heading  is  included  cases 
of  incomplete  abortion  which  give  rise  either  to  continued  bleeding- 
metrorrhagia^or  to  evidence  of  infection  from  decomposition  of  the 
retained  secundines.  In  each  the  indication  is  the  same — to  clean  the 
uterus  as  gently  as  possible.  The  need  for  gentleness  is  especially  great 
in  the  infected  cases,  as  the  uterine  w^all  is  extremely  soft  and  perforation 
of  it  by  the  curette  is  very  easy. 

After-treatment. — One  of  the  most  important  results  of  abortion,  espe- 
cially induced  abortion,  has  been  the  subinvolution  and  endometritis" 
arising  from  the  neglect  of  the  precautions  which  are  recognized  as  neces- 
sary at  term  and  generally  observed.  Many  women  remain  quiet  but  a 
few  days  following  a  miscarriage,  and  even  if  they  escape  the  dangers 
arising  from  an  incomplete  abortion,  often  suffer  for  years  from  the 
subinvolution,  displacement  and  endometritis  which  might  have  been 
avoided  by  proper  care. 

Patients  after  abortion,  just  as  reasonably  as  after  childbirth  at  term, 
should  be  kept  in  bed  until  the  uterus  has  had  a  chance  to  involute. 
It  is  the  author's  custom  to  keep  them  in  bed  at  least  a  week  and  not 
allow  them  to  go  out  of  the  house  for  at  least  two  weeks.  Attention  should 
be  called  to  the  fact  that  after  abortion,  as  after  labor  at  term,  there  is 
often  a  tendency  of  the  uterus  to  retrovert  and  patients  should  not  be 
allowed  to  go  about  until  it  is  determined  either  that  the  uterus  has 
remained  in  normal  position  or  it  has  been  replaced  and  supported  with  a 
pessary  if  it  was  retro  verted. 

Treatment  of  Habitual  Abortio?i. — No  matter  how  anxious  a  woman 
may  be  at  certain  periods  of  her  life  to  get  rid  of  the  product  of  her  con- 
ception, there  often  comes  a  time  when  her  greatest  desire  is  to  bear  a 
child,  but  whether  or  not  the  previous  abortions  have  been  induced,  the 


TREATMENT  OF  ABORTION  521 

occurrence  of  one  miscarriage  after  another  tends  to  reproduce  this 
result  in  subsequent  pregnancies  and  so  bring  about  the  miscarriage 
habit,  or  the  condition  of  habitual  abortion.  The  etiology  is  largely 
based  on  the  pathological  changes  in  the  uterus,  namely,  the  subinvolu- 
tion and  endometritis  resulting  in  the  formation  of  unhealthy  deciduse. 
Back  of  this  may  lie  a  constitutional  dyscrasia  such  as  syphilis,  and  this 
should  always  be  sought  for  and  treated  if  found  in  a  case  suffering 
from'  habitual  abortion. 

It  must  be  recognized  that  the  successful  treatment  of  habitual  abor- 
tion is  often  extremely  difficult  and  attempts  in  this  direction  often  meet 
with  disappointment.  In  the  first  place  the  pelvic  organs  should  be 
gotten  into  as  normal  a  condition  as  possible  before  pregnancy  is  allowed. 
At  least  a  year  and  perhaps  more  than  that  time  should  elapse  between 
the  last  miscarriage  and  a  subsequent  pregnancy  in  order  to  allow  the 
subinvolution  to  subside.  If  the  endometritis  persists  a  curettage  will 
often  give  the  quickest  and  most  effective  result.  If  the  cervix  shows 
extensive  lacerations,  they  should  be  repaired.  When,  after  a  suitable 
interval,  pregnancy  has  again  occurred,  certain  precautions  should  be 
taken.  In  the  first  place  all  sexual  intercourse  must  be  interdicted. 
Furthermore,  in  well-marked  cases,  the  patient  should  remain  in  bed 
each  month  on  the  days  which  would  naturally  be  those  of  menstrua- 
tion. If  there  is  the  slightest  suspicion  of  syphilitic  infection  it  should 
receive  constitutional  treatment.  The  urine  should  be  carefully  watched 
for  evidences  of  a  toxemia  and  the  avenues  of  elimination  be  kept  in 
functional  activity. 

Between  the  times  which  would  normally  be  the  menstrual  periods  the 
patient  may  be  allowed  a  little  more  liberty,  but  in  those  whose  tendency 
to  abort  is  very  great  it  may  be  necessary  to  keep  them  off  their  feet 
during  a  large  part  of  the  time  until  after  the  period  of  their  former 
miscarriages  has  passed.  The  author's  custom  is  to  allow  the  patient 
out  of  bed  a  few  hours  each  day  during  the  weeks  which  would  not  be 
her  menstrual  weeks,  but  she  should  avoid  stair  climbing  and  all  rough 
motoring  and  should  simply  seek  fresh  air  without  fatigue.  If  once  the 
pregnancy  can  be  safely  brought  to  term  the  so-called  habit  is  usually 
broken  and  little  trouble  experienced  in  the  future. 


MAT 


CHAPTER  XVI. 

ECTOPIC  GESTATION.    PREGNAN(  Y  IN  MALFORMED 

UTERI. 

ECTOPIC   GESTATION. 

The  normal  situation  for  an  impregnated  ovum  to  lodge  and  develop 
is  within  the  cavity  of  the  uterus.  A  pregnancy  located  anywhere  else, 
as  being  out  of  place,  is  called  ectopic  gestation.  This  term  covers  not 
only  those  conditions  which  are  strictly  extra-uterine  but  also  a  preg- 
nancy in  the  interstitial  ])ortion  of  the  tube  which  while  ectopic  is  not 
outside  of  the  uterus. 

The  first  clearly  recorded  case  of  ectopic  gestation  is  one  described  in 
the  eleventh  century  by  Albucasis/  an  Arabian  physician,  who  observed 
parts  of  a  fetus  working  their  way  through  the  abdominal  wall.  During 
the  seventeenth  century  more  exact  descriptions  are  given  and  different 
varieties  are  mentioned.  In  1614  Mercerus"^  performed  an  autopsy 
upon  a  woman  who  had  died  of  a  ruptured  ectopic  gestation  of  two 
months,  probably  tubal  or  tuboovarian,  although  regarded  by  him  as 
ovarian.  During  the  seventeenth  century  the  distinction  between  primary 
and  secondary  abdominal  gestation  was  clearly  made. 

Frequency. — For  centuries  ectopic  gestation  was  considered  one  of 
the  rarest  of  accidents  to  which  woman  was  liable,  but  since  March  3, 
1883,  when  Lawson  Tait,  of  Birmingham,  England,  performed  his  first 
successful  operation  upon  a  case  of  ruptured  ectopic  gestation,  literature 
has  abounded  in  reports  of  cases  of  this  condition  and  every  busy  gyne- 
cologist is  called  upon  to  operate  upon  several  of  these  cases  each  year. 
Some  idea  of  the  frequency  of  the  condition  may  be  gained  from  the 
fact  that  Formad,  of  Philadelphia,  in  3500  general  autopsies,  found  35 
ectopic  gestations.  In  one  series  of  500  abdominal  sections  performed 
by  the  author  for  different  pelvic  conditions  there  were  38  cases  of  ectopic 
gestation.  In  assigning  credit  for  our  knowledge  of  this  condition  it 
is  only  just  to  state  that  to  Lawson  Tait  and  his  views  regarding  the 
etiology  and  treatment  of  pehic  hematocele  we  owe  most  of  our  present 
practical  knowledge  of  the  subject. 

Varieties. — In  1752  Bohmer  adopted  a  classification  of  ectopic  gesta- 
tion which  may  well  be  accepted  today,  viz.,  tubal,  ovarian,  ahdominaL 

For  many  years  the  existence  of  an  ovarian  pregnancy  was  subject  to 
grave  doubt,  but  in  the  last  decade  the  carefully  recorded  cases  of  Van 
Tussenbrook,  of  Amsterdam,  Thompson,  of  Portland,  Webster,  of  Chicago 
(2  cases),  Davis,  of  Philadelphia,  and  others  lea^'e  no  doubt  that  true 

1  De  Chirurgia,  cura  J.  Channing,  Oxon,  1778. 
-  Anthropographia  et  Osteologia,  Parisiis,  1626. 

(522) 


ECTOPIC  GESTATION 


523 


ovarian  pregnancy  does  exist  as  a  variety  of  ectopic  gestation,  although 
very  rare.  A  case  of  ovarian  pregnancy  operated  upon  by  the  author  is 
shown  in  Figs.  328,  329,  330,  and  331 .  That  primary  abdominal  pregnancy 
can  occur  in  the  sense  that  an  ovum  free  in  the  abdominal  cavity  is  met 
and  fertilized  by  a  spermatozoon  and  there  develops,  is  extremely  diffi- 
cult to  believe  when  the  marked  absorptive  power  of  the  peritoneum 
is  considered.  On  the  other  hand,  many  instances  are  recorded  where 
the  fetus,  after  partial  development  within  the  tube,  or  between  the 
folds  of  the  broad  ligament,  has  escaped  secondarily  into  the  abdominal 

Ovary  containing  blood-clot 


Left  tube  overlying  a  parovarian  cyst 


Fig.  328. — Ovarian  pregnancy,  seen  from  above. 


cavity  and  continued  its  existence,  although  in  these  cases  the  placenta 
has  usually  maintained  its  attachment  either  within  the  tube  or  between 
the  folds  of  the  ligament.  These  are  cases  of  secondary  abdominal 
gestation. 

The  ovarian  and  abdominal  varieties  of  this  condition  are  so  rare 
that  for  practical  purposes  ectopic  gestation  may  ordinarily  be  looked 
upon  as  primarily  tubal. 

It  may  be  situated  in  different  portions  of  the  tube  and  receive  different 
names,  as  for  instance: 

In  the  interstitial  portion  called  tuho-uterine  or  interstitial.  This 
variety  is  rare,  constituting  only  about  3  per  cent,  of  cases. 


524    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

In  the  tube  proper,  called  trve  tubal.  In  this  variety  the  gestation  may 
lie  in  any  one  of. the  three  sites:  the  isthmus,  the  ampulla,  or  in  the 
fimbriated  extremity. 

It  may  lie  between  the  tube  and  the  ovary,  called  tubooMrian. 

Secondary  varieties  of  ectopic  gestation  are  those  resulting  from  dis- 
placement of  the  ovum  after  its  primary  lodgement. 

This  displacement  may  take  place  either  into  the  abdominal  cavity  by 
abortion  through  the  fimbriated  extremity  of  the  tube,  constituting  a 


Fig.  329. — Ovarian  pregnancy,  seen  from  below  and  without. 


secondary  abdominal  pregnancy,  or  down  through  the  floor  of  the  tube, 
constituting  an  intraligamentous  pregnancy,  perhaps  escaping  thence  by 
rupture  of  the  broad  ligament  folds  into  the  abdominal  cavity,  constitut- 
ing also  a  secondary  abdominal  pregnancy.  In  a  few  cases  of  interstitial 
pregnancy  the  ovum  seems  to  have  been  discharged  into  the  uterine 
cavity,  becoming  an  intra-uterine  pregnancy. 

In  summing  up  the  varieties  of  ectopic  gestation  the  following  may 
be  recognized: 


ECTOPIC  GESTATION 


525 


Primary  Ectopic  Gestation: 

Tubo-uterine  or  interstitial. 
[  Isthmial. 

True  tubal  \  Ampullar. 

[  Infundibular. 

Tuboovarian. 

Ovarian 
Secondary  Ectopic  Gestation: 

Abdominal. 

Intraligamentous. 


526    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

Etiology. — In  studying  tlie  causes  of  ectopic  gestation  the  normal 
site  of  impregnation  must  first  he  considered.  In  animals,  spermatozoa 
have  heen  found  in  the  tube  and  in  the  pelvic  cavity  surrounding  the 
ovary  in  from  two  and  three-quarter  to  twenty  hours  after  intercourse. 
An  autopsy,  performed  sixteen  hours  after  death,  upon  a  girl  who  died 
of  coal-gas  poisoning  immediately  after  intercourse-showed  spermatozoa 
in  the  tube.  It  is  known  that  the  ovum  requires  several  days  to  pass 
along  the  tul)e  from  o\ar\'  to  uterus. 


Fig.  331. — Ovmiiiu  pregnancy.     Vifw  of  chorionic  villi  shown  in  Fig.  33U,  under  liiglier 

magnification.      X  75. 

It  therefore  follows  that  the  normal  meeting-place  of  ovum  and 
spermatozoon  is  in  the  tube,  and  it  is  generally  recognized  that  the  tube 
is  the  normal  site  of  impregnation  and  that  the  ordinary  forms  of  ectopic 
gestation  result  from  some  hindrance  to  the  advance  of  the  impregnated 
ovum  along  the  tube  toward  the  uterus  and  the  partial  development  of 
the  ovum  at  the  point  of  detention. 

In  the  case  of  ovarian  pregnancy  the  ovum  is  impregnated  before  it 
leaves  the  ovary  and  undergoes  partial  development  there.  Conditions 
causing  delay  in  the  j)rogress  of  the  ovimi  along  the  tube  may  be 
situated : 


ECTOPIC  GESTATION  527 

1.  In  the  lumen  of  the  tube. 

2.  In  the  wall  of  the  tube. 

3.  Outside  the  wall  of  the  tube. 

4.  In  the  ovum  itself. 

Conditions  in  the  Lumen  of  the  Tube. — Here  may  be  mentioned  many 
hindrances  to  the  advance  of  the  o\'um  such  as  diverticula;  strictures; 
inflammation  of  the  mucosa  resulting  in  damaged  cili?e;  polypi,  and  in 
rare  cases  even  a  previous  ectopic  gestation,  as  in  the  case  reported  by 
Coe/  in  which  at  the  time  of  operation  for  ruptured  ectopic  gestation 
on  the  right  side  the  remains  of  an  ectopic  gestation,  which  had  occurred 
twelve  years  previously,  was  found  obstructing  the  proximal  end  of  the 
same  tube. 

Conditions  in  the  Wall  of  the  Tube. — The  thickening  of  the  tubal  wall 
resulting  from  a  previous  salpingitis  interferes  with  the  normal  peris- 
taltic action  and  probably  favors  the  arrest  of  the  fertilized  ovum  within 
the  tube. 

Conditions  Outside  the  Wall  of  the  Tube. — Pelvic  tumors,  especially 
fibromyomata  of  the  uterus  may  so  compress  the  tube  as  to  narrow  the 
lumen  and  arrest  the  ovum.  Adhesions  between  the  tube  and  adjacent 
structures  may  by  their  traction  cause  angulation  of  the  tube  and  thus 
bring  about  an  obstruction  to  the  passage  of  the  ovum  to  the  uterus. 

Condition  of  the  Ovum  Itself. — The  passage  of  the  ovum  toward  the 
uterus  may  be  so  slow  or  over  so  circuitous  a  route  that  its  development 
reaches  a  size  which  is  too  large  to  pass  through  the  lumen  of  the  tube. 
This  is  seen  especially  in  twin  ectopic  gestation  and  in  external  migration 
of  the  ovum. 

External  migration  of  the  ovum  is  quite  common  in  ectopic  gestation. 
J.  W.  ^Yilliams  being  able  to  demonstrate  it  in  5  out  of  30  cases. 

In  the  case  of  H.  C.  Coe,  already  referred  to,  the  proximal  portion  of 
the  right  tube  was  entirely  blocked  by  a  lithopedion,  while  external  to 
this  was  a  ruptured  gestation  sac,  the  ovum  having  come  from  the  left 
ovary  and  been  impregnated  by  spermatozoa  passing  through  the  left 
tube,  as  the  right  ovary  was  small,  atrophic  and  surrounded  by  adhesions, 
while  the  left  ovary  contained  a  recent  corpus  luteum. 

In  a  case  of  the  author's,  on  operation  a  ruptured  ectopic  gestation 
was  found  in  the  left  tube,  although  eleven  years  before  he  had  removed 
the  left  ovary  for  a  dermoid  cyst.  This  must  have  been  a  case  of  external 
migration  of  the  ovum,  which  had  come  from  the  right  ovary,  passecf 
around  the  uterus  and  entered  the  distal  end  of  the  left  tube. 

Kelly  reports  an  interesting  case  from  which  he  had  removed  a  diseased 
left  ovary  and  right  tube,  leaving  a  normal  right  ovary  and  left  tube,  and 
who  fifteen  months  later  gave  birth  to  a  child  at  term  and  who  seventeen 
months  after  delivery  was  obliged  to  have  the  left  tube  removed  for 
ruptured  ectopic  gestation. 

One  of  the  most  recent  theories  of  the  etiology  of  ectopic  gestation, 
and  one  which  furnishes  a  most  plausible  explanation,  in  some  cases  at 

1  New  York  Medical  Record,  May  27,  1S93. 


528    ECTOPIC  GE  ST  A'T  I  ON— PREGNANCY  IN  MALFORMED   UTERI 

least,  is  that  of  Otto  V.  Hiiffman,i  of  the  Long  Island  College.  It  is  what 
he  calls  the  anomalous-embedding-area  theory.  While  searching  for 
some  confirmation  of  the  inflammation  or  ol3striiction  theories  in  a 
very  remarkable  specimen  of  tnbular  pregnancy  removed  at  necropsy, 
he  found  two  supernumerary,  but  rudimentary.  Fallopian  tubes,  one 
attached  to  each  of  the  fully  developed  tubes.  Inasmuch  as  there  was 
no  evidence  of  obstruction  or  inflammation  having  caused  the  tubular 
pregnancy,  he  inferred  that,  early  in  the  embryological  development  of 
this  individual  there  was  a  duplication  of  the  Miillerian  ducts  and  that, 
with  the  subsidence  in  the  growth  of  one  pair,  those  portions  which  should 


Fig.  332. — Dr.  Childs's  case  of  twin  ectopic  gestation.  (Jour.  Am.  Med.  Assoc,  Ucccnibor 
28,  1907.)  A,  amniotic  sac;  C,  ruptured  segment  lying  free  from  the  remainder  of  the  tube 
except  for  a  slight  peritoneal  attachment. 

have  formed  a  second  uterus,  with  all  the  factors  that  determine  an 
implantation  area,  became  lodged  as  "rests"  in  the  walls  of  the  fully 
developed  tubes,  and  that  one  of  these  "rests"  of  embedding  tissue 
permitted  the  ovum  to  embed  at  the  abnormal  site.  With  this  as  his 
working  hypothesis,  he  carefully  examined  68  specimens  of  ectopic  preg- 
nancy and  found  malformations  of  the  tube  or  ovary  in  54  per  cent, 
of  them.  This  result,  in  face  of  the  difficulty  of  examining  torn  and 
very  often  incomplete  material,  along  with  the  fact   that  the   lower 


1  Ectopic  Pregnancy  Associated  with  Anomalous  Fallopian  Tubes,  Surg.,  Gynec.  and 
Obst.,  May,  1913;  A  Theory  of  the  Cause  of  Ectopic  Pregnancy,  Jour.  Amer.  Med.  Assoc, 
December,  1913,  p.  2130. 


ECTOPIC  GESTATION 


529 


mammals  are  known  to  have  definite  embedding  or  placentation  areas 
scattered  throughout  their  uteri,  seemed  to  him  to  justify  th£  theory  of 
anomalous  embedding  areas  being  the  cause  of  ectopic  pregnancy,  and 
he  pointed  out  that  all  other  theories  had  lost  sight  of  the  essential  mutual 


Fig.  333 


1  — 


Fig.  334 


Figs.  333  and  334. — Combined  ectopic  and  intra-uterine  gestation;  operation  five  months 
after  miscarriage.  Fig.  333,  tube  and  ovarj'  removed  at  operation;  1,  gestation  sac  containing 
amnion  and  gi\dng  chorionic  villi  under  the  microscope;  2,  fimbriated  extremity;  3,  ovary. 
Fig.  334,  fetus  contained  -within  its  membranes,  passed  from  the  uterus  on  the  day  following 
the  operation.     (American  Text-book  of  Gynecology.) 

relation  of  the  ovum  and  the  embedding  site  which  obtains  in  the  normal 
physiology  of  embedding.  While  as  yet  embedding  tissue  cannot  be 
identified  morphologically,  such  specialized  tissue  is  known  to  exist  in 
scattered  areas  in  the  long  double  uteri  of  the  lower  mammals — scattered 
presumably  to  prevent  all  the  ova  from  embedding  at  the  upper  ends  of 
34 


530     ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

the  uteri  and  to  get  a  proper  distribution  of  the  Htter;  this  makes  Huff- 
man's theory  quite  plausible. 

Multiple  and  Repeated  Ectopic  Gestation. — Ectopic  gestation  like  intra- 
gestation  may  be  single  or  multiple.  There  may  be  found  two  embryos 
in  the  same  tube,  usually  called  twin  tubal  pregnancy,  as  illustrated  by 
the  case  of  Dr.  Charles  G.  Child,  Jr.,  of  New  York,  of  which  Fig.  332  is 
a  photograph.  On  the  other  hand,  there  may  be  one  embryo  in  each  tube, 
called  bilateral  tubal  pregnancy. 

Dr.  L.  P.  McCalla,^  of  Boise,  Idaho,  has  collected  from  the  literature 
25  cases  of  the  former  (twin-tubal  pregnancy)  and  together  with  one 
of  his  own  37  cases  of  the  latter  (bilateral  tubal  pregnancy). 

Ectopic  gestation  may  occur  simultaneously  with  intra-uterine  gesta- 
tion, as  is  illustrated  by  the  case  of  the  author's  (see  Figs.  333  and  334), 
in  which  he  operated  for  the  ruptured  ectopic  gestation  one  evening 
and  the  patient  passed  the  intra-uterine  embryo  enveloped  in  its  mem- 
branes on  the  following  day. 

Ectopic  gestation  may  be  repeated  in  the  same  tube,  as  illustrated  in 
the  case  of  Dr.  H.  C.  Coe,  already  referred  to,  in  which  the  lithopedion 
resulting  from  the  former  ectopic  gestation  obstructed  the  passage  along 
the  tube  of  the  ovum  of  the  second. 

Ectopic  gestation  may  occur  in  one  tube  at  one  time  and  in  the  opposite 
tube  subsequently,  as  is  illustrated  by  the  author's  case  upon  whom  he 
operated  February  25,  1905,  for  ectopic  gestation  with  ruptured  right 
tube  and  who  subsequently  (September  6,  1906)  required  operation  for 
an  ectopic  gestation  in  the  left  tube.  Before  each  operation  the  patient 
passed  from  the  uterus  a  complete  decidual  sac;  Fig.  335  being  a  photo- 
graph of  the  one  passed  just  prior  to  the  operation  in  1905. 

In  the  author's  service  at  the  Sloane  Hospital  during  the  last  three 
and  a  half  years,  35  cases  of  ectopic  gestation  have  been  operated  upon, 
among  which  there  were  6  cases  which  had  previously  been  operated 
upon  for  ectopic  gestation.  In  5  of  these  cases  the  second  ectopic  gesta- 
tion sac  was  on  the  opposite  side  from  the  first,  while  in  1  case  it 
occurred  for  the  second  time  on  the  same  side,  the  tube  not  having  been 
removed  at  the  first  operation. 

For  a  long  time  it  was  thought  that  a  previous  history  of  sterility, 
showing  difficulty  in  impregnation,  was  an  important  feature  of  ectopic 
gestation. 

In  a  recent  analysis,  however,  by  Frank^  of  80  cases  occurring  at  Mount 
Sinai  Hospital,  New  York,  only  12  of  the  entire  series  had  never  been 
previously  pregnant,  and  6  of  these  acquired  their  ectopic  gestation  dur- 
ing the  first  six  months.  It  will  thus  be  seen  that  sterility  plays  a  very 
imimportant  part  in  the  condition. 

The  occurrence  of  ectopic  gestation  in  the  first  pregnancy  in  12  out  of 
SO  cases  reported  as  above  by  Frank,  and  in  3  out  of  43  cases  reported 
by  Doderlein,  shows  the  relative  infrequency  of  ectopic  gestation  in  the 
first  pregnancy. 

'  Surgery,  Gynecology  and  Obstetrics,  March,   1909,  p.  248. 
-'  Amer.  Jour.  Obst.,    1909,  vol.  lix,  No.  2. 


ECTOPIC  GESTATION 


531 


Pathology. — Changes  in  the  Uterus. — The  uterus  enlarges  both  its  walls 
and  cavity  along  w'ith  the  development  of  the  ectopic  gestation  but  to 
a  lesser  degree  than  at  a  corresponding  period  of  intra-uterine  pregnancy. 
The  degree  of  uterine  enlargement,  moreover,  varies  directly  with  the 
proximity  of  the  gestation  sac  to  the  uterine  wall.  As,  for  instance,  it  is 
much  greater  in  an  interstitial  pregnancy  than  in  a  tuboovarian  gesta- 
tion. The  softened  feel  of  the  uterus  so  characteristic  of  normal  intra- 
uterine pregnancy  is  present  in  ectopic  gestation,  but  to  a  very  limited 
extent.  Within  the  cavity  of  the  uterus  in  a  case  of  ectopic  gestation 
there  is  formed  a  decidua  corresponding  to  the  decidua  parietalis  of  a 
normal  intra-uterine  pregnancy,  but  as  there  is  no  ovum  lodged  upon  it, 


y 


I 


r.\ 


.y-fe?vf 


Fig.  .335. — Decidual  cast;  ectopic  gestation. 

there  is  no  decidua  capsularis  (reflex),  and  no  decidua  basalis.  It  is 
rough  and  shaggy  on  its  outer  surface  where  it  adheres  to  the  uterine 
wall,  relatively  smooth  but  wrinkled  on  its  inner  surface  (see  Fig.  336). 
This  decidua  is  seen  in  sitii  in  Fig.  337,  which  is  a  photograph  of  a  speci- 
men removed  by  the  author  on  account  of  fibromyomata  at  the  time  of 
operation  for  the  ruptured  gestation  sac. 

This  decidua  is  usually  cast  off  in  small  fragments  between  the  eighth 
and  twelfth  week,  often  near  the  time  of  tubal  rupture  or  abortion,  but 
occasionally  it  is  cast  off  en  masse,  as  seen  in  Fig.  335,  already  referred  to. 
The  microscopic  appearance  of  this  decidua  is  shown  in  Fig.  338. 

This  discharge  of  the  decidua  is  accompanied  by  more  or  less  bleeding. 


532    ECTOPIC  GESTATIOX—PREGXANCl^  IX   MALFORMED   UTERI 

Changes  in  the  Fallopian   Tube. — Occasionally  when  the  pregnancy  is 
normal  and  intra-nterine,  decidual  cells  are  found  in  the  Fallopian  tubes 


Fig.  336. — Decidua  expelled  from  the  uterus  in  a  case  of  ectopic  gestation:  A,  rotated 
so  as  to  show  the  shaggy  uterine  side;  B,  shows  the  free  surface.  Author's  specimen. 
(American  Text-book  of  Gj-necolog}\) 


Fig.  337. — Decidua  iti  situ;  fibroid  uterus  removed  at  time  of  operation  for  ruptured  ectopic 
gestation.     (American  Text-book  of  Gynecology.) 


(Lange,  Mandel).  In  ectopic  gestation  this  is  ahvays  the  case  and  there 
is  formed  a  more  or  less  incomplete  decidual  membrane  which  as  the 
ovum  lodges  and  develops  becomes  differentiated  into  a  pseudodecidua 


ECTOPIC  GESTATION 


533 


capsularis  and  decidiia  basalis  corresponding  to  what  normally  develops 
in  the  uterus  after  the  lodgement  of  the  ovum.  As  might  be  expected, 
however,  neither  of  these  decidual  coverings  are  as  complete  in  the  tube 
as  in  the  uterine  cavity  and  when  it  is  considered  that  the  decidual  lining 
serves  practically  as  a  protection  to  the  maternal  tissue  against  the  in- 
roads of  the  chorionic  villi,  with  their  trophoblastic  covering,  it  is  readily 
understood  that  in  the  tube  with  an  imperfect  and  scanty  decidual  mem- 
brane the  fetal  ^'illi  easily  erode  and  invade  the  tubal  wall,  opening 
maternal  vessels  and  weakening  the  tubal  wall  which  when  compared 
with  the  uterine  wall  is  little  suited  to  accommodate  a  growing  embryo. 
In  a  normal  intra-uterine  pregnancy,   along  with  the  growth  of  the 


Fig.  338. — Photomicrograph  of  a  section  of  decidua  in  a  case  of  ectopic  gestation,  showing 
the  large  decidual  cells.     (American  Text-book  of  Gynecology.) 


embryo  and  fetus  there  occurs  a  progressive  h\'pertrophy  and  hyperplasia 
of  the  muscular  structure  of  the  uterine  wall. 

In  a  tubal  pregnancy  during  the  early  weeks  of  gestation  a  similar 
change  occurs  in  the  muscular  structure  of  the  tubal  wall,  but  this  hyper- 
trophy and  hyperplasia  soon  cease  and  after  the  first  few  weeks  the 
muscle  fibers  are  found  separated  and  the  gestation  sac  composed  largely 
of  connective  tissue.  The  thickness  of  the  gestation  sac  varies  in  different 
portions.  In  some  places  it  is  thickened  by  hemorrhages  into  the  sub- 
stance of  the  wall,  and  by  inflammatory  deposit  upon  the  exterior.  In 
other  places  it  is  thinned  by  stretching  of  the  tubal  wall  coincident  with 
the  growth  of  the  ovum  or  by  the  occurrence  of  an  intratubal  hemorrhage. 


534    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

The  fetal  troi^hoblast  in  its  eroding  action  may  open  np  the  decidua 
capsnhiris  and  set  free  the  ovnni  into  the  hnnen  of  the  tube  and  force 
it  along  this  canal  and  out  of  the  fimbriated  extremity  by  the  pressure 
of  the  hemorrhage  coming  from  the  eroded  maternal  vessels. 

On  the  other  hand  the  fetal  villi  may  penetrate  and  even  perforate 
the  muscle  wall  and  peritoneal  covering  of  the  tube,  thus  making  an 
avenue  of  escape.  The  most  usual  process  of  tubal  rupture  is  the  yielding 
of  the  tubal  wall  under  the  increased  tension  of  a  sudden  hemorrhage 
within  it,  due  to  the  opening  of  a  large  maternal  vessel. 

Directions  of  Escaye  from  the  l\ihe.- — The  ovum  in  tubal  gestation 
may  excape  from  the  tube  in  four  different  directions  in  the  following 
order  of  frequency: 

Outward,  by  tubal  abortion  through  fimbriated  extremity  (see  Fig.  339). 

Uyimrd,  hy  rupture  into  the  peritoneal  cavity  (see  Fig.  340). 


r' t' 


o  vap-"^ 


Fig.  339. — Tubal  abortion. 

Downward,  by  rupture  between  the  folds  of  the  broad  ligament  (see 
Fig.  341). 

Inward,  by  extension  of  an  interstitial  pregnancy  into  the  cavity  of 
the  uterus — rare. 

Tvhal  Abortion. — The  escape  of  the  impregnated  ovum  through  the 
fimbriated  extremity  of  the  tube  into  the  peritoneal  cavity  is  regarded 
by  practically  all  observers  today  as  much  the  most  frequent  termination 
of  tubal  gestation:  The  percentage  generally  accepted  is  about  75  per 
cent,  tubal  abortions  to  25  per  cent,  tubal  ruptures.  These  percentages 
vary  greatly  in  the  records  of  different  hospitals.  Thus  in  a  series  of  60 
cases  of  tubal  pregnancy  reported  by  Newell/  of  Boston,  there  were  22 
tubal  abortions  and  22  tubal  ruptures,  but  in  14  cases  the  pregnant  tube 
was  removed  before  rupture  or  abortion  had  occurred.  In  a  series  of  80 
consecutive  cases  of  ectopic  gestation  occurring  at  the  Mount  Sinai 


1  International  Clinics,  vol.  iv,  15th  series. 


ECTOPIC  GESTATION 


535 


Hospital,  New  York,  and  reported  by  Frank,^  there  were  42  tubal  rup- 
tures and  only  20  tubal  abortions;  but  there  were  11  hematoceles  and  4 
pregnant  tubes  removed  before  rupture  or  abortion.  In  a  series  of  289 
cases  collected  from  literature  by  J.  W.  Williams  there  were  22  per  cent, 
tubal  ruptures. 

In  forming  an  estimate  of  the  frequency  of  tubal  abortion  it  must  be 
remembered  that  in  many  cases  of  this  condition  the  ovum  has  undoubt- 
edly been  entirely  expelled  from  the  tube,  the  hemorrhage  has  ceased 
and  the  patient  has  recovered  without  operation,  or  an  hematocele  has 
formed  which  has  been  drained  through  the  vagina  without  opportunity 
to  examine  the  tube  and  determine  whether  it  was  a  rupture  or  abortion. 


Fig.  340 


Fig.  341 


A  tubal  abortion  usually  occurs  before  the  fimbriatedjextr^ity  is 
closed,  {.  e.,  during  the  first  twojaootJba^jaLthe^geslHionr^t  may,  how- 
ever,  occur  later  if  the  fimbriated  extremity  is  not  firmly  closed. 

It  is  easily  seen  that  the  probability  of  a  tubal  abortion  is  greatest 
when  the  ovum  is  implanted  near  the  fimbriated  extremity  and  this 
probability  decreases  as  the  site  of  implantation  approaches  the  cornu 
of  the  uterus.  If  lodged  in  the  isthmus  of  the  tube — that  straight,  nar- 
row portion  just  outside  the  cornu  of  the  uterus — as  the  lumen  is  small 
and  does  not  easily  distend,  the  ovum  makes  room  for  itself  by  erosion 
of  the  tubal  wall  which  easily  leads  to  rupture,  rather  than  tubal 
abortion. 

In  the  ordinary  conditions  of  tubal  abortion  with  the  ovum  lodged 
either  in  the  ampulla  or  in  the  fimbriated  extremity,  the  inroads  of  the 
trophoblast  cause  a  hemorrhage  which  ruptures  the  decidua  capsularis, 


1  Amer.  Jour.  Obst.,  1909,  vol.  lix,  No.  2. 


53(3    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

usually  destroys  the  life  of  the  ovum,  and  usually,  but  not  always  expels 
it  more  or  less  t'()m])l('tely  from  the  tube.  Three  outcomes  are  therefore 
possible. 

1.  The  ovum  may  remain  for  a  longer  or  shorter  period  in  the  tube  as 
a  tubal  mole. 

2.  It  may  be  completely  expelled  from  the  tube,  giving  a  complete 
tubal  abortion. 

3.  It  may  be  only  partially  expelled  from  the  tube,  giving  an  incom- 
plete tubal  a})ortion. 

If  the  tubal  abortion  is  complete  and  the  tube  left  empty,  the  hemor- 
rhage from  the  tube  into  the  peritoneal  cavity,  although  it  may  be 
profuse  at  the  time,  soon  ceases.  This  is  analogous  with  the  outcome 
of  a  complete  uterine  abortion.  It  should  be  remembered,  however, 
that  in  the  process  of  expelling  the  ovum,  before  the  abortion  becomes 
complete  the  hemorrhage  may  be  so  profuse  as  nearly  to  exsanguinate 
the  patient,  as  has  occurred  in  the  author's  experience. 

On  the  other  hand,  as  in  an  incomplete  uterine  abortion,  so  long  as 
the  tubal  abortion  is  incomplete  subsequent  hemorrhages  are  to  be 
expected.  According  to  Wormser,  the  incomplete  tubal  abortions  are 
ten  times  as  frequent  as  the  complete.  In  a  few  cases,  with  the  fimbriated 
extremity  closed,  the  hemorrhage  setting  free  the  ovum  within  the  tube 
may  so  disorganize  and  destroy  it  that  only  an  hematosalpinx  results 
which  is  gradually  absorbed,  as  is  sometimes  the  case  with  a  pelvic 
hematocele  resulting  from  a  complete  tubal  abortion. 

Tjihal  Rupture. — As  a  result  of  the  inroads  of  the  chorionic  villi  with 
their  trophoblastic  covering,  the  vessels  of  the  tubal  wall  which  have 
become  enlarged  during  the  pregnancy  are  opened,  and  the  weakened 
tubal  wall,  unable  to  withstand  the  tension  caused  by  the  hemorrhage 
gives  way,  allowing  more  or  less  of  the  ovum  to  escape  either  upward  into 
the  peritoneal  cavity  (see  Fig.  342)  or  downward  between  the  folds  of 
the  broad  ligament. 

The  former,  intraperitoneal  rupture  is  much  more  common  and  more 
serious  than  the  latter,  as  in  the  former  the  open  vessels  may  continue 
to  pour  forth  blood  into  the  peritoneal  cavity,  while  in  the  latter  the 
hemorrhage  takes  place  into  a  confined  space  which  is  extraperitoneal. 

The  escape  of  the  ovum  from  the  tube  by  tubal  rupture  occurs  in  about 
25  per  cent,  of  cases.  The  site  of  this  rupture  is  usually  in  that  portion 
of  the  tube  corresponding  to  the  decidua  basalis  where  the  invasion  of 
the  trophoblast  has  been  the  deepest.  As  in  a  tubal  abortion  the  escape 
from  the  tube  at  the  time  of  the  hemorrhage  may  be  either  complete  or 
incomplete.  In  the  incomplete  escape  the  ovum  may  plug  the  opening 
for  a  time  until  subsequent  hemorrhage  resulting  from  further  inroads 
of  the  chorion  villi  forces  it  out  of  the  tube. 

Escape  of  the  ovum  into  the  cavity  of  the  uterus  occurs  only  in  that 
form  of  ectopic  gestation  called  interstitial  or  tvho-uterine  pregnancy, 
where  the  ovum  has  lodged  or  partly  developed  in  the  interstitial  portion 
of  the  tube.  This  variety  of  ectopic  gestation  is  one  of  the  rarest  and 
in  its  termination  may  present  either  the  most  favorable  or  the  gravest 


ECTOPIC  GESTATION  537 

outcome  of  all.  In  its  most  favorable  termination  it  is  simply  forced 
gradually  from  the  interstitial  (intramural)  portion  of  the  tube  into  the 
uterine  cavity  and  continues  its  development  as  a  normal  intra-uterine 
pregnancy.  The  diagnosis  of  this  condition  and  outcome  is  almost 
impossible  to  accurately  determine,  as  it  is  extremely  difficult  to  differ- 
entiate it  from  a  pregnancy  in  which  the  impregnated  ovum  has  lodged 
and  developed  in  the  horn  of  the  uterine  cavity  and  which  gives  in  the 
early  months  a  very  asymmetrical  uterus,  but  which  later  presents  a 
uterus  of  normal  shape.  Instead  of  this  favorable  termination  of  an 
interstitial  pregnancy  the  opposite  is  the  more  common.  Surrounded 
as  it  is  by  the  muscular  structure  of  the  uterine  wall  it  is  easy  to  under- 


FiG.  342. — Tubal  rupture:  A,  ruptured  tube;  B,  uterine  end  of  tube;  C,  fimbriated  extremity. 

stand  that  here  a  growing  embryo  can  be  much  more  easily  accommo- 
dated and  for  a  much  longer  time  than  in  any  other  portion  of  the  tube, 
and  instead  of  a  rupture  of  the  sac  occurring  before  the  twelfth  week,  as 
most  often  occurs  in  every  other  variety  of  tubal  pregnancy,  here  rupture 
does  not  usually  take  place  until  four  to  six  months,  but  when  the  rup- 
ture does  occur  the  event  is  apt  to  be  much  more  rapidly  fatal  on  account 
of  the  larger  sinuses  which  have  developed  in  the  decidua  basalis  and  the 
surrounding  uterine  tissue. 

Exciting  Causes  of  Tubal  Rupture  or  Abortion. — In  our  study  of  the 
pathology  of  ectopic  gestation  we  have  learned  that  the  real  causes  of 
escape  of  the  ovum  from  the  tube  are  (1)  the  erosion  of  the  tubal  ivall  by 


538    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

the  chorionic  villi  with  their  trophoblastic  covering,  (2)  tJie  hemorrhage 
from  the  nioternal  vessels  opened  by  this  trophoblastic  erosion. 

On  the  one  hand  we  have  a  weakening  of  the  capsule  surronnding  the 
ovum,  and  on  the  other  an  increase  in  the  tension  within  it.  A  yielding 
is  the  natural  result.  This  result  may  occur  without  the  intervention  of 
any  outside  exciting  causes,  as  is  illustrated  by  the  fact  that  occasionally 
in  ectopic  gestation  a  tubal  rupture  or  abortion  A^ill  occur  when  the 
patient  is  lying  quietly  asleep  in  bed.  On  the  other  hand  it  is  easily  under- 
stood that  when  the  predisposing  causes  are  present  in  the  tube,  any 
exciting  cause  increasing  intra-abdominal  pressure  may  determine  the 
event.  In  several  of  the  author's  cases  the  history  was  obtained  that 
the  rupture  or  abortion  followed  speedily  upon  sexual  intercourse.  In 
other  cases  a  gynecological  examination;  straining  at  stool;  lifting  a 
weight;  some  traumatism;  or  the  arrival  of  the  period  of  menstrual 
congestion  has  seemed  to  be  the  exciting  cause  which  determined  the 
rupture  or  abortion. 

In  studying  the  different  varieties  of  tubal  pregnancy  we  have  learned 
that  the  escape  of  the  ovum  from  the  tube  by  abortion  or  rupture  takes 
place  at  different  times  according  to  the  site  of  lodgement  in  the  tube. 

Tubal  abortion  usually  occurs  before  the  closure  of  the  fimbriated 
extremity,  which  ordinarily  takes  place  at  about  eight  weeks  of  tubal 
gestation.  It  must  be  remembered,  however,  that  if  the  ovum  lodges 
and  develops  in  the  tube  near  the  fimbriated  extremity  it  may  keep  this 
extremity  open  for  a  longer  period.  Tubal  rupture  occurs  latest  (four 
to  six  months)  in  the  interstitial  variety  of  ectopic  gestation  because  the 
surrounding  muscular  wall  is  thicker  and  more  easily  adapted  to  the 
growing  embryo. 

On  the  other  hand  tubal  rupture  occurs  earliest  (4  to  6  weeks)  in 
the  isthmial  variety  of  ectopic  gestation  where  the  ovum  lodges  in  the 
straight  narrow  portion  of  the  tube  just  beyond  the  interstitial  portion. 

The  lumen  is  small,  not  easily  distensible,  and  the  trophoblast  soon 
erodes  the  wall  to  form  a  bed  for  the  oAum  and  this  erosion  soon  leads  to 
rupture. 

When  the  ovum  is  lodged  in  the  ampulla  of  the  tube  it  finds  a  larger 
lumen  and  a  more  distensible  wall  and  rupture  does  not  usually  occur 
until  the  gestation  has  advanced  to  from  eight  to  twelve  weeks.  Before 
leaving  the  discussion  of  the  period  of  tubal  rupture  or  abortion  atten- 
tion should  be  called  to  the  fact  that  in  rare  instances  the  life  of  the 
embryo  ceases  and  in  the  condition  of  a  mole  or  lithopedion  it  is  retained 
in  the  tube  for  months  or  even  years  without  the  occurrence  of  either 
abortion  or  rupture. 

Moreover,  with  the  ovum  partly  within  and  partly  without  the  tube, 
fetal  life  in  exceptional  cases  may  continue  until  the  completion  of  the 
full  period  of  gestation.  This  will  be  referred  to  later  under  the  heading 
of  Advanced  Ectopic  Gestation. 

Changes  in  the  Ovum. — So  long  as  the  life  of  the  ectopic  ovum  continues 
it  develops  along  normal  lines  just  as  though  resting  in  its  normal  bed 
in  the  uterine  cavitv. 


ECTOPIC  GESTATION 


539 


The  Placenta. — In  ectopic  gestation  the  placenta  differs  from  that  in 
normal  intra-uterine  pregnancy  only  in  the  imperfect  formation  of  the 
decidua.  The  amnion  and  chorion  which  constitute  the  fetal  portion  are 
well  developed,  but  with  the  scanty  and  imperfect  decidual  formation 
it  is  easy  to  understand  the  incompleteness  of  the  maternal  portion. 

The  escape  of  the  ovum  from  the  tube  either  by  abortion  or  rupture 
usually  terminates  the  life  of  the  embryo.  In  fact  it  may  be  said  that 
the  rupture  of  the  pseudodecidua  capsularis,  setting  the  ovum  free  in  the 
lumen  of  the  tube,  also  accomplishes,  as  a  rule,  the  same  result. 

In  either  case,  whether  retained  in  the  tube  or  expelled  from  it  by 
abortion  or  rupture,  a  hemorrhage  usually  "accompanies  the  change  of 


■^^•^^^^«m 


Fig.  343. — Ectopic  gestation,  showing  blood-clot  and  chorionic  villi  in  the  tube. 


lodgement  and  if  the  ovum  is  small  it  will  be  found  surrounded  with  a 
blood-clot  producing  a  tubal  mole  (see  Fig.  343),  or  a  blighted  ovum 
(see  Fig.  344)  in  the  interior  of  which  are  found  chorionic  villi  and 
usually  a  small  amniotic  cavity. 

x\s  stated  above,  the  escape  of  the  ovum  from  the  tube  by  either  abor- 
tion or  rupture  usually  marks  the  death  of  the  ovum,  and  this  applies 
whether  the  escape  is  into  the  peritoneal  cavity  or  between  the  folds  of 
the  broad  ligament.  Exceptions  to  this  rule  will  be  mentioned  later.  If 
discharged  into  the  peritoneal  cavity,  the  ovum  with  its  accompanying 
hemorrhage  gravitates  to  the  pouch  of  Douglas,  and  if  the  women  sur- 
vive the  hemorrhage  and  shock  the  blood  forms  a  pelvic  hematocele, 


540    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

becoming  roofed  in  by  the  coils  of  intestine  which  float  above  it  and 
become  adherent  to  each  otlier.  If  tlie  ovum  is  not  further  advanced 
than  two  months  of  gestation  and  the  hemorrhage  not  too  great  in  amount 
both  ovum  and  effused  blood  may  be  entirely  absorbed.  The  absorptive 
power  of  the  peritoneum  is  so  great  that  in  some  cases  much  older  ova 
than  two  months  and  enormous  hematoceles  are  absorbed.  The  prox- 
imity of  the  rectum,  however,  and  the  ready  soil  of  the  blood-clot  makes 
infection  of  the  hematocele  and  blighted  ovum  easy,  hence  a  suppurating 
hematocele  is  not  an  vmcommon  result  of  an  ectopic  gestation  which  has 
not  been  operated  u]ion  and  while  a  fetus  which  has  advanced  lieyond 


Fig.  344. — Blighted  ovum  discharged  by  rupture  of  tube. 


the  fourth  month  may  remain  quiescent  in  the  abdomen  for  months  or 
years,  being  changed  to  a  lithopedion  or  undergoing  a  mummification, 
still  suppuration  of  the  sac  and  soft  parts  of  the  fetus  may  be  expected 
at  any  time  with  the  accompanying  effort  on  the  part  of  nature  to  expel 
the  fetal  skeleton  through  the  rectum,  the  bladder,  or  even  through  the 
abdominal  wall,  as  w'as  described  by  Albucasis  in  the  eleventh  century. 
In  some  cases  of  advanced  ectopic  gestation  the  fetus  has  been  found 
alive  in  the  peritoneal  cavity  surrounded  only  by  the  fetal  envelopes, 
and  attempts  have  been  made  to  explain  its  location  by  the  theory  that 
after  the  discharge  of  the  ovum  from  the  tube  into  the  peritoneal  cavity 


ECTOPIC  GESTATION  541 

it  engrafted  itself  afresh  upon  the  peritoneum  and  there  developed. 
This  theory  the  author  has  never  been  able  to  accept  as  either  rational 
or  borne  out  by  the  findings  in  cases  of  advanced  ectopic  gestation  oper- 
ated on  by  him.  AYhen  it  is  considered  how  uniformly  fetal  death  fol- 
lows complete  separation  of  the  chorion  from  its  attachment  in  a  uterine 
pregnancy,  it  is  impossible  to  believe  that  any  other  result  would  follow 
this  separation  in  a  tubal  pregnancy.  This  will  be  referred  to  again 
when  discussing  advanced  ectopic  gestation,  but  for  the  present  it  is 
sufficient  to  state  that  when  an  o^iim  is  completely  discharged  from  a 
tube  into  the  cavity,  either  by  abortion  or  rupture,  three  outcomes  are 
possible  if  the  patient  survives  the  hemorrhage  and  shock: 

1.  If  small  it  may  be  completely  absorbed. 

2.  It  may  suppurate. 

3.  It  ma.y  mummify  or  be  changed  to  a  lithopedion. 
Intraligamentous  Rupture. — ^^Vhen  the  rupture  occurs  in  the  floor  of 

the  tube  and  the  ovum  is  discharged  with  hemorrhage  down  between 
the  folds  of  the  broad  ligament  a  dift'erent  condition  prevails.  The  blood 
is  effused  into  a  confined  space  and  the  hemorrhage  is  usually  checked 
by  the  pressure  produced  by  the  tension  of  the  distended  ligament.  Thus 
producing  a  broad  ligament  hematoma.  Rarely  the  folds  of  the  broad 
ligament  yield  under  the  excessive  tension  and  a  secondary  rupture 
occurs  from  the  broad  ligament  into  the  peritoneal  cavity  and  we  then 
have  conditions  resembling  those  found  in  the  intraperitoneal  abortion 
or  rupture. 

When  the  ovum  is  discharged  between  the  folds  of  the  broad  ligament 
the  rule  is,  as  in  the  intraperitoneal  rupture,  that  fetal  life  ceases;  if  small 
the  o\Tim  may  be  absorbed,  although  the  absorptive  power  of  connective 
tissue  is  less  than  that  of  the  peritoneal  cavity  and  suppuration  of  the 
pelvic  hematoma  resulting  from  an  intraligamentous  rupture  is  not  un- 
common. The  continuation  of  fetal  life  in  an  intraligamentous  rupture 
will  be  studied  later. 

Symptoms. — The  SATnptoms  of  ectopic  gestation  may  well  be  studied 
under  two  groups: 

1.  Those  occurring  before  tubal  rupture  or  abortion. 

2.  Those  occurring  at  the  time  of  tubal  rupture  or  abortion. 
Before   Tubal  Rupture  or  Abortion. — Prior  to  the  occurrence  of  the 

hemorrhage  which  determines  the  escape  of  the  0M.mi  from  the  tube 
the  symptoms  may  either  be  absent  altogether  or  extremely  few.  The 
patient  may  feel  absolutely  well  and  have  no  idea  that  she  is  pregnant, 
or  she  may  have  the  usual  symptoms  of  early  pregnancy  but  be  entirely 
ignorant  that  anything  is  abnormal,  least  of  all  that  she  is  carrying 
within  her  abdomen  the  possibility  of  one  of  the  most  serious  experiences 
to  which  woman  is  liable. 

Occasionally,  however,  a  woman  will  suffer  with  a  vague  feeling  of 
discomfort,  or  an  indefinite  pain  on  one  side  of  the  pelvis  and  will  seek 
her  physician  to  ascertain  its  cause.  Often  under  these  circumstances 
and  occasionally  in  the  early  routine  examination  of  a  patient  supposedly 
pregnant  it  is  possible  to  diagnose  the  presence  of  ectopic  gestation 


542    ECTOPIC  GESTATIOX—PREGXAXCY  IX  MALFORMED    UTERI 

prior  to  the  period  of  tubal  rupture  or  abortion.  In  all  probability  the 
presence  of  vague  pains  in  the  region  of  the  gestation  sac  often  means 
the  occurrence  of  small  hemorrhages  insufficient  in  amount  to  cause 
rupture  of  the  sac. 

Before  tubal  rupture  or  abortion,  a  rule  which  the  author  has  found 
of  great  j)ractical  value  in  diagnosing  ectopic  gestation  is  as  follows: 
//  a  pregnant  patient  ha^  a  mass  at  the  side  of  the  litems,  ahcays  think  of 
the  possibility  of  ectopic  gestation.  Having  obtained  a  history  of  possible 
pregnancy,  with  a  uterus  somewhat  softened  and  congested  and  an 
elongated  mass  at  the  side  of  the  uterus  with  vessels  about  it  pulsating 
distinctly,  the  diagnosis  of  an  unruptured  ectopic  gestation  can  often 
be  made  correctly  in  spite  of  the  fact  that  a  tube  or  ovary,  the  seat  of 
chronic  inflammation,  may  lead  to  many  errors. 

.1^  the  Time  of  Tubal  Rupture  or  Abortion. — The  clinical  picture  of  a 
patient  at  the  time  of  tubal  rupture  or  abortion  is  a  typical  one  and 
should  be  impressed  upon  the  mind  of  e\ery  practising  physician  and 
surgeon. 

The  sudden  sharp  abdominal  pain  causing  the  patient  to  "double  up," 
as  the  expression  is;  the  feeling  of  faintness;  the  pallor;  the  rapid  and 
feeble  pulse;  the  rapid  respiration;  the  air  hunger;  the  cold  perspira- 
tion; the  nausea  and  the  subnormal  temperature — these  all  point  to 
the  true  condition  present,  viz.,  shock  and  internal  hemorrhage. 

A  rule  which  the  author  has  found  of  great  practical  value  is  as  follows: 
7/  a  married  woman,  living  with  her  hvsband,  has  a  sudden  sharp  abdom- 
inal pain  with  symptoms  of  collapse,  always  think  of  ectopic  gestation. 

Diagnosis. — To  establish  a  diagnosis  of  ectopic  gestation  there  must 
be  added  to  this  clinical  picture  the  patient's  history  and  the  physical  signs. 

Patient's  History. — The  most  important  feature  in  this  history  is  the 
question  of  possible  pregnancy,  and  for  this  the  obstetrician  naturally 
looks  to  the  irregularity  of  her  menstruation.  While  many  instances 
have  occurred  in  which  a  patient  has  suffered  from  a  tubal  rupture  or 
abortion,  although  her  last  menstruation  was  normal  in  time  of  occurrence, 
amount  and  duration,  this  is  exceptional  and  the  rule  is  that  at  the  last 
menstrual  period  either  the  menstruation  was  skipped  or  it  was  abnormal 
either  in  time  of  occurrence,  amount  or  duration.  Often  instead  of  the 
normal  free  flow  at  the  regular  time  there  is  only  a  spotting  of  the 
napkins  followed  later  by  a  more  or  less  irregular  brownish  discharge 
containing  shreds. 

Nausea,  vomiting,  a  feeling  of  fulness  in  the  breasts  and  the  usual 
subjective  symptoms  of  pregnancy  may  be  present  and  the  patient  thinks 
she  is  progressing  favorabh-  in  a  normal  pregnancy  when,  to  the  surprise 
of  everyone,  she  is  suddenly  seized  with  a  severe,  sharp  pain  on  one  side 
of  her  abdomen  with  the  faintness,  nausea,  rapid  pulse  and  respiration 
and  the  other  features  of  the  clinical  picture  described  above. 

L  sually  about  this  time  the  menorrhagia  appears  and  may  continue 
for  several  weeks,  being  due  to  the  separation  of  the  uterine  decidua. 

As  shreds  are  usually  passed  with  the  discharge  the  patient  often 
thinks  she  has  had  a  miscarriage  and  that  her  troubles  will  soon  be  over. 


ECTOPIC  GESTATION  543 

Following  this  attack  of  pain,  symptoms  of  pelvic  peritonitis  often 
present  themselves.  These  may  subside  and  the  patient  be  around  as 
usual  when  she  is  suddenly  seized  with  another  attack  of  sharp  pain, 
syncope,  etc.,  perhaps  even  worse  than  before.  The  decidual  membrane 
(see  Fig.  335),  while  usually  passed  in  fragments,  is  sometimes  discharged 
en  masse,  as  in  the  author's  case  here  illustrated,  and  when  found  is  of 
great  aid  in  diagnosis. 

The  history  of  a  period  of  previous  sterility  was  formerly  considered 
of  marked  value  in  diagnosis,  but  as  already  stated,  this  is  now  looked 
upon  as  of  little  importance. 

The  following  features  in  the  history  may  be  considered  most  worthy 
of  note : 

1.  Amenorrhea,  or  some  departure  from  the  normal  menstruation. 

2.  Symptoms  of  pregnancy. 

3.  The  occurrence  of  sudden,  sharp  pain  with  syncope. 

4.  An  irregular  metrorrhagia. 

Physical  Signs. — Before  the  occurrence  of  tubal  rupture  or  abortion  the 
physical  signs,  as  already  indicated,  are  those  of  an  enlarged  tube  with 
perhaps  the  additional  signs  of  increased  vascularity  and  congestion  due 
to  pregnancy.  The  uterus  may  feel  a  little  larger  and  softer  than  normal 
with  cervix  a  little  patulous,  and  sometimes  the  arterial  pulsation  on  the 
side  of  the  pelvis  corresponding  to  the  site  of  the  gestation  sac  is  rather 
abnormally  distinct.  The  breasts  in  a  primigravida  may  show  sufficient 
engorgement  and  stimulation  to  be  of  value  in  diagnosis,  although  in  a 
multigravida  the  breast  changes  are  seldom  of  much  importance. 

At  the  time  of  tubal  rupture  or  abortion  the  physical  signs  will  depend 
very  largely  upon  whether  the  ovum  has  escaped  into  the  peritoneal 
cavity  or  down  between  the  folds  of  the  broad  ligament,  i.  e.,  whether  the 
escape  is  intraperitoneal  or  extraperitoneal.  If  intraperitoneal,  there 
may  be  scarcely  any  physical  signs  to  be  detected.  If  the  tube  has  emptied 
itself  either  by  rupture  or  abortion,  as  may  happen  if  the  event  occurs 
early  in  the  gestation,  the  condition  is  that  of  a  movable  uterus,  a  col- 
lapsed tube  and  a  larger  or  smaller  amount  of  free  blood  in  the  pelvis. 
Somewhere  in  this  free  blood  and  usually  in  the  pouch  of  Douglas  is  the 
early  ovum,  as  indicated  in  Fig.  345. 

On  considering  the  conditions  it  is  easy  to  understand  how  few  physical 
signs  may  be  present.  The  increase  in  size  of  the  uterus  may  be  so  slight  ■ 
as  not  to  be  palpable,  especially  if  the  amount  of  free  blood  in  the  abdom- 
inal cavity  is  large.  The  question  then  resolves  itself  into  the  physical 
signs  of  free  blood  in  the  pelvis.  The  skilled  fingers  will  sometimes  diag- 
nose the  condition  of  the  vague  feeling  of  fulness  in  the  vaginal  fornices 
and  the  lessened  distinctness  with  which  the  pelvic  organs  are  palpated. 
Moreover,  with  the  effusion  of  blood  in  the  pelvis  there  occurs  a  floating 
upward  of  the  intestines  which  causes  more  or  less  distention  of  the 
abdomen. 

Sufficient  has  now  been  said  to  show  that  the  physical  signs  present 
at  the  time  of  tubal  abortion  or  intraperitoneal  rupture  may  be  very 
meagre  and  the  diagnosis  must  be  made  largely  from  the  history  of  the 


544    ECTOPIC  GEST AT lOX— PREGNANCY  IX  MALFORMED    UTERI 

case  and  the  general  condition  of  anemia  and  shock  in  wliich  the  patient 
is  found. 

If  tlie  ovum  has  escaped  with  hemorrhage  (h)wn  hetween  the  folds  of 
the  broad  ligament,  the  conditions  are  difi'erent  and  distinct  physical 
signs  are  present.  We  have  now  an  encapsulated  hemorrhage  giving 
a  distinct  mass  at  the  side  of  the  uterus,  bulging  down  on  one  side,  and 
lichind  the  cervix,  pushing  the  uterus  upward,  forward  and  toward  the 
opposite  side  and  opening  up  the  folds  of  peritoneum  which  forms  the 
broad  ligament  so  that  the  mass  may  be  felt  above  Poupart's  ligament. 
If  the  gestation  sac  occurred  on  the  left  side  of  the  pelvis  the  peritoneum 


Ruptured 
tube 


Ovum 


Fig.  .345. — Ovum  surrounded  by  blood-clot,  discharged  by  rupture  of  the  tube. 


is  lifted  from  the  rectum  v.hich  is  more  or  less  surrounded  by  the  hemor- 
rhage, so  that  a  finger  introduced  into  the  canal  detects  the  stricture-like 
feel  caused  by  the  attachment  of  the  tense  peritoneum  to  its  second 
portion. 

Subsequent  to  Tubal  Rupture  or  Abortion. — If  the  patient  is  examined 
several  days  after  intraperitoneal  rupture  or  abortion  the  conditions 
have  changed;  the  blood  has  clotted  and  has  become  encapsulated  by 
the  adhesion  of  the  coils  of  intestine  which  floated  above  it  and  we  now 
have  a  i)elvic  hematocele  with  distinct  physical  signs.  The  bimanual 
examination  detects  a  boggy  mass  behind  and  to  one  side  of  the  uterus 
and  this  boggy  mass  taken  in  connection  with  the  history  of  some  of  the 


ECTOPIC  GESTATION  545 

symptoms  of  pregnancy;  an  irregular  metrorrhagia;  the  occurrence  of 
an  attack  of  sudden,  sharp  pain  and  evidences  of  shock  and  internal 
hemorrhage  will  usually  enable  every  careful  observer  to  make  the  cor- 
rect diagnosis. 

The  blood  examination  showing  a  diminution  of  hemoglobin  and  the 
number  of  red  cells  and  a  slight  leukocytosis  has  often  proved  of  value. 

Differential  Diagnosis. — The  condition  for  which  ectopic  gestation  is 
most  often  mistaken,  alike  by  the  patient  and  her  medical  attendant,  is 
an  early  miscarriage.  In  each  there  are  symptoms  of  pregnancy,  hemor- 
rhage, pain  and  the  passing  of  something  from  the  uterus.  It  is  not 
strange  that  the  two  conditions  are  confused,  and  it  is  here  that  the  rule 
already  given,  if  a  pregnant  patient  has  a  mass  at  the  side  of  the  uterus, 
always  think  of  the  possibility  of  ectopic  gestation,  so  often  proves  of 
value. 

As  an  illustration  of  the  frequency  of  this  error  it  may  be  stated  that 
many  a  patient  has  been  curetted  for  the  supposed  retained  secundines 
of  a  miscarriage  and  only  portions  of  decidua  obtained  which  showed 
under  the  microscope  no  chorionic  villi.  In  endeavoring  to  differentiate 
between  a  miscarriage  and  ectopic  gestation  the  following  differential 
features  may  be  of  value: 

Miscarriage vs. — Ectopic  Gestation. 

Uterus  larger,  cervix  more  patulous.  Uterus  smaller,  cervix  less  patulous. 

No  mass  felt  at  side  of,  or  behind,  the  uterus.  Perhaps  mass  felt  at  the  side  of,  or  behind, 

the  uterus. 

No  tenderness  or  distention  of  the  abdomen.  Both  may   be   present. 

No  evidences  of  shock  and  internal  hemor-  Both  present  if  tubal  rupture  or  abortion 

rhage.  has  occurred. 

Mass   discharged    from    the   uterus   shows  Mass  shows  only  decidual  cells,  no  chorionic 

chorionic  villi.  villi. 

Another  condition  sometimes  confused  with  ectopic  gestation  is  a  tube 
distended  with  either  serum  or  pus,  especially  the  latter.  The  physical 
signs  of  the  two  conditions  prior  to  rupture  often  closely  resemble  one 
another  and  just  as  the  rupture  of  an  ectopic  gestation  sac  is  followed 
by  symptoms  of  shock  and  then  peritonitis,  so  may  the  rupture  or  leakage 
of  a  pus  tube  be  followed  by  similar  symptoms.  The  chief  feature  in 
their  differentiation  rests  in  the  differences  in  their  clinical  history. 

In  the  case  of  ectopic  gestation  there  is  perhaps  obtainable  the  symp- 
toms of  pregnancy,  while  in  the  other  there  is  the  history  of  previous 
pelvic  inflammation. 

Subsequent  to  the  rupture  the  following  differences  can  usually  be 
noted : 

Ruptured  Ectopic  Gestation vs. Ruptured  Pyosalpinx. 

Frequency  of  pulse  greater.     Temperature  Frequency    of    pulse    less.       Temperature 

at  first  subnormal;  later  rises  slightly.  rises   steadily   and  markedly. 

Patient  shows  loss  of  blood.  Patient  does  not  show  blood  loss. 

Pain  of  shorter  duration  (septic  symptoms  Pain  of  longer   duration.      Signs   of    sepsis 

usually  not  present).  soon  present. 

Blood  examination  shows  anemia.  Blood  examination  does  not  show    anemia. 


Leukocytosis  greater. 


35 


546    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 


The  condition  called  membranous  dysmenorrhea  is  one  which  may 
be  confused  with  ectopic  gestation  when  the  decidua  is  discharged  en 
masse  or  in  large  pieces  as  in  each  case  there  is  an  absence  of  chorionic 
villi,  but  the  history  of  frequent  recurrence  of  a  discharge  of  membrane 
at  a  menstrual  period  with  the  absence  of  any- 
mass  at  the  side  of  the  uterus  and  the  absence 
of  symptoms  of  pregnancy  will  usually  enable 
one  to  diagnose  that  variety  of  dysmenorrhea 
called  membranous.  It  is  perfectly  possible, 
however,  that  some  of  the  cases  diagnosed  as 
membranous  dysmenorrhea  which  occurred  only 
once  were  cases  of  tubal  abortion  in  which  the 
decidua  was  expelled  and  the  early  ovum  after 
discharge  into  the  peritoneal  cavity  was  ab- 
sorbed without  operation  and  without  a  correct 
diagnosis. 

A  menstrual  cast  from  a  case  of  membranous 

dysmenorrhea  is  shown  in  Fig.  346,  which  may 

be  compared  with  that  of  ectopic  gestation  shown 

in  Fig.  347. 

The  menstrual  cast  is  never  more  than  4  x  2.5  cm.,  while  the  decidual 

cast  of  ectopic  gestation  may  be  as  large  as  8  x  4  cm.    The  menstrual 

cast  is  thinner  and  more  fragile  than  that  of  ectopic  gestation.     The 

difference  in  appearance  under  the  microscope  is  shown  in  Figs.  348  and 


Fig.  346.  —  Menstrual 
cast  expelled  from  a  case 
of  membranous  dysmenor- 
rhea in  a  virgin. 


Fig.  347. — Decidual  cast  expelled  from  a  case  of  ectopic  pregnancy  before  operation. 
It  is  split  open  to  show  the  inner  surface  which  is  smooth;  it  has  the  grooves  which  are  also 
characteristic  of  decidua. 


349  which  are  photomicrographs  of  a  decidua  of  pregnancy  and  a  men- 
strual decidua.  In  the  decidua  of  pregnancy  the  cells  are  larger,  the 
nuclei  are  well  defined,  dense,  and  homogeneous.  In  the  menstrual 
decidua  the  cells  are  smaller,  the  nuclei  are  less  dense  and  are  pyknotic. 


ECTOPIC  GESTATION 


547 


It  may  seem  strange,  at  first  thought,  that  a  fibromyoma  of  the  uterus 
and  an  ectopic  gestation  should  ever  be  confused,  yet  this  has  occurred 
in  a  number  of  instances  where  the  patient  presented  the  symptoms  of 
early  pregnancy  and  examination  detected  a  mass  at  the  horn  of  the 
uterus.  If  the  patient  has  not  previously  been  examined  and  the  pres- 
ence or  absence  of  a  fibroid  determined,  it  is  easy  to  understand  why 
several  questions  should  arise: 


Fig.  348. — Decidua  compacta  from  a  case  of  early  (uterine)  abortion.       X  500.     Note 
the  larger  cells  with  dense,  homogeneous,  well-defined  nuclei. 


Is  it  a  normal  pregnancy  and  a  fibromyoma  ?  Is  it  an  ectopic  gestation 
either  interstitial  or  isthmial?  Is  it  an  ectopic  gestation  of  the  ampullar 
variety  in  which  a  hemorrhage  has  occurred  into  the  tube  and  the  preg- 
nant tube  and  ovary  have  become  adherent  to  the  side  of  the  uterus? 
Is  it  a  combined  intra-uterine  and  ectopic  gestation? 

Many  of  these  questions  it  may  be  impossible  to  answer  positively 
until  the  occurrence  of  a  sudden,  sharp  pain  with  symptoms  of  shock  and 
internal  hemorrhage  mark  the  case  as  one  of  tubal  rupture  or  abortion, 
whatever  else  may  be  present. 

Each  case  must  be  studied  by  itself,  and  perhaps  the  growth  of  the  mass 


548    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

watched  for  a  time,  but  certain  features  of  a  fibromyoma  which  differ 
from  those  of  pregnancy  must  always  })e  borne  in  mind:  the  slow  growth; 
the  firm  circumscribed  character;  the  insensitiveness;  the  tendency  to 
cause  menorrhagia  rather  than  amenorrhea,  and  finall>'  the  frequency 
with  which  one  fibromyoma  is  found  accompanied  by  others  in  the 
same  uterus. 


1  lii  ^  *■ 


Fig.  349. — Stroma  cells  of  endometrium  removed  from  a  virgin  the  day  before  the  men- 
strual flow  was  due.  X  500.  Note  the  size  of  the  cells  in  comparison  with  the  decidual 
cells  in  Fig.  348.     Also  compare  the  nuclei;  here  they  are  not  so  dense  and  are  pyknotic. 


Where  both  fibromyoma  and  an  ectopic  gestation  coexist,  as  in  the 
author's  case  (see  Fig.  337),  the  diagnosis  may  be  exceedingly  difficult 
prior  to  tubal  rupture  or  abortion. 

The  diagnosis  of  interstitial  ectopic  gestation  prior  to  rupture  of  the 
sac  is  one  which  should  be  made  w^ith  great  care  and,  as  a  rule,  only  after 
several  examinations  at  repeated  intervals,  for  the  reason  that  in  many 
cases  of  intra-uterine  pregnancy  the  ovum  is  lodged  in  one  horn  of  the 
uterine  cavity  and  in  its  early  development  gives  to  the  uterus  an  asym- 
metrical shape  which  might  easily  be  mistaken  for  an  interstitial  ectopic 
gestation. 


ECTOPIC  GESTATION  549 

If  time  is  allowed  and  the  development  of  the  ovum  followed,  the 
uterus  is  seen  to  gradually  assume  its  symmetrical  shape  and  the  preg- 
nancy is  seen  to  be  normal  and  intra-uterine.  An  early  and  rash  diag- 
nosis of  interstitial  ectopic  gestation  might  have  led  to  a  needless  and 
embarrassing  operation.  The  diagnosis  of  combined  intra-uterine  and 
ectopic  gestation  is  seldom  made  until  the  symptoms  and  physical  signs 
of  the  other  are  seen  to  continue  after  the  ovum  has  been  discharged 
either  from  the  tube  or  from  the  uterus.  In  the  author's  case  (see 
Figs.  333  and  334)  he  did  not  suspect  the  presence  of  the  intra-uterine 
pregnancy  at  the  time  of  the  operation  for  the  ruptured  ectopic  gestation 
and  was  only  made  aware  of  its  presence  when  the  ovum  was  passed 
from  the  uterus  on  the  following  morning. 

Advanced  Ectopic  Gestation. — As  already  stated,  the  life  of  the  ovum 
usually  ceases  at  the  time  of  its  discharge  from  the  tube,  whether  its  dis- 
charge is  by  tubal  rupture  or  tubal  abortion  and  whether  the  discharge  is 
intraperitoneal  or  extraperitoneal,  i.  e.,  between  the  folds  of  the  broad 
ligament.  In  a  few  instances,  however,  probably  for  the  reason  that  the 
original  placental  attachment  was  but  little  disturbed,  fetal  life  con- 
tinues and  may  go  to  term  or  even  beyond  it  and  the  child  may  reach 
perfect  development.  On  the  other  hand,  fetal  life  may  cease  at  any 
period  between  the  time  of  the  primary  tubal  rupture  or  abortion  and 
term,  on  account  of  a  separation  of  more  of  the  placenta,  perhaps  by 
secondary  rupture  of  the  sac  and  accompanying  hemorrhage,  than  is 
needed  for  fetal  life  and  development.  Several  varieties  of  advanced 
ectopic  gestation  may  present  themselves.  According  to.  the  author's 
experience  the  most  common  variety  is  the  intraligamentous,  in  which  the 
rupture  of  the  tube  has  occurred  in  its  floor  where  it  was  uncovered  by 
peritoneum.  Of  the  6  cases  of  advanced  ectopic  gestation  operated  on 
by  the  author,  4  were  of  this  variety,  although  this  is  a  much  greater 
frequency  than  is  given  by  most  authors. 

The  folds  of  the  broad  ligament  are  opened  out  and  lifted  up;  the 
uterus  is  pushed  upward,  forward  and  to  the  opposite  side  and  in  this 
extraperitoneal  space  the  life  of  the  fetus  may  continue  to  full  develop- 
ment. This  life  and  development  depends  upon  the  non-disturbance 
of  a  sufficient  area  of  the  placenta  to  provide  for  the  needs  of  the  fetus. 

As  the  growth  of  the  fetus  continues  the  maternal  portion  of  the  ges- 
tation sac  formed  by  the  folds  of  the  broad  ligament  may  rupture  with 
the  escape  of  the  fetus  into  the  abdominal  cavity.  This  event  may  be 
accompanied  by  more  or  less  separation  of  the  placenta  and  with  suffi- 
cient hemorrhage  to  kill  both  mother  and  child,  or  the  placental  separation 
and  hemorrhage  may  be  slight  and  fetal  life  may  continue  in  the  abdom- 
inal cavity,  although  the  placenta  still  remains  attached  in  the  cavity 
formed  partly  by  tubal  wall  and  partly  by  distended  broad  ligament. 

This  forms  one  variety  of  abdominal  pregnancy,  being  secondary  to  an 
intraligamentous  pregnancy.  In  most  of  these  cases  the  fetus  is  still 
surrounded  by  its  amnion  and  chorion  laive  reinforced  by  adherent  coils 
of  intestine.  In  some  cases,  however,  it  has  been  impossible  to  identify 
these  membranes,  and  this  has  given  rise  to  the  probable  erroneous 


550    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

idea  of  a  primary  abdominal  pregnancy.  At  tlie  present  time  most 
authorities  agree  that  a  primary  abdominal  pregnancy  in  the  sense  of  an 
ovum  being  discliarged  into  the  peritoneal  cavity,  forming  an  attach- 
ment to  any  portion  of  the  peritoneum  and  developing  there,  does  not 
occur. 

In  another  variety  of  advanced  ectopic  gestation  the  fetal  sac  has 
been  gradually  extended  from  the  tube  either  through  the  fimbriated 
extremity,  as  occurred  in  one  of  the  autlior's  cases,  or  through  a  rupture 
through  the  wall  of  the  tube  which  did  not  greatly  disturb  the  placental 
attachment. 

As  the  fetus  is  gradually  extruded  from  the  tube  into  the  peritoneal 
cavity  surrounded  by  its  amnion  and  chorion,  the  fetal  sac  is  reinforced 
by  the  coils  of  intestine  which  surround  it  and  become  adherent  to  it,  and 
into  which  the  chorionic  villi  may  imbed  themselves.  This  constitutes 
the  tnho-ahdominal  variety  of  advanced  ectopic  gestation,  the  placenta 
being  still  retained  more  or  less  within  the  cavity  of  the  tube  while  the 
rest  of  the  ovum  lies  within  the  abdominal  cavity.  Here  again  a  second- 
ary rupture  may  extrude  the  fetus  into  the  abdominal  cavity.  From 
consideration  of  the  above  it  will  be  seen  that  the  location  and  attach- 
ment of  the  placenta  in  cases  of  advanced  ectopic  gestation  depend 
largely  upon  the  site  of  its  attachment  in  the  tube  at  the  time  of  the 
escape  of  the  ovum. 

In  the  intraligamentous  pregnancy,  if  the  placenta  was  attached 
chiefly  to  the  roof  of  the  tube  at  the  time  of  rupture,  it  would  lie  above 
the  fetus  as  pregnancy  advanced,  and  being  raised  by  the  growing  fetus 
the  placenta  might  be  brought  in  contact  with,  and  form  adhesions  to, 
the  viscera  of  the  abdomen.  If  the  placenta  was  attached  to  the  side 
or  the  floor  of  the  tube  at  the  time  of  the  rupture,  the  villi  of  its  per- 
iphery might  spread  over  the  floor  of  the  pelvis  and  attach  themselves  to 
the  large  vessels  found  there.  In  the  tubo-abdominal  variety  the  ex- 
panding periphery  of  the  placenta  may  attach  its  villi  to  the  intestines 
and  any  viscus  with  which  they  come  in  contact,  thus  forming  very  inti- 
mate adhesions  and  making  removal  by  operation  very  difficult.  At  one 
time  it  was  thought  that  the  placenta  in  certain  instances  at  least  con- 
tinued its  growth  after  the  death  of  the  fetus.  At  the  present  day  the 
apparent  increase  in  the  size  of  the  placenta  which  occasionally  occurs 
after  the  death  of  the  fetus  is  understood  as  caused  by  a  hemorrhage 
into  its  substance  or  between  it  and  its  site  of  attachment  due  to  the 
inroads  of  the  trophoblastic  covering  of  its  villi.  The  symptoms  of 
advanced  ectoyic  gestation  vary  greatly  in  different  cases.  In  some  cases 
the  escape  from  the  tube  is  so  gradual  that  the  woman  has  few  symp- 
toms at  this  time;  thinks  they  are  simply  the  discomforts  to  be  expected 
in  pregnancy,  and  by  the  time  she  is  seen  by  the  obstetrician  may  have 
forgotten  all  about  them.  This  was  the  condition  in  one  of  the  author's 
cases  who  came  to  the  hospital  just  before  term  expecting  a  normal 
confinement.  On  close  questioning  she  recalled  the  fact  that  at  about 
the  third  month  she  had  an  attack  like  "inflammation  of  the  bowels," 
and  thought  she  had  a  miscarriage  but  later  felt  life  and  it  had  been  very 


ECTOPIC  GESTATION  551 

distinct,  so  distinct  in  fact  that  the  fetal  movements  had  annoyed  her 
greatly.  As  a  rule,  if  the  woman  and  the  fetus  survive  its  escape  from 
the  tube,  the  T\'oman  passes  through  a  period  of  pelvic  inflammation 
depending  in  extent  upon  the  amount  of  hemorrhage  accompanying  the 
tubal  rupture.  At  about  this  time  the  decidua  is  discharged  from  the 
uterus  with  more  or  less  metrorrhagia,  so  that  it  is  not  unnatural  that  a 
miscarriage  with  inflammation  following  should  be  the  diagnosis  of  the 
laity. 

After  this  period  of  pelvic  inflammation  is  passed  the  pregnancy  may 
progress  normally  to  term  or  the  woman  may  pass  through  another 
stormy  period,  perhaps  fatal  to  both  herself  and  the  fetus,  due  to  a  second- 
ary rupture  of  the  gestation  sac  into  the  peritoneal  cavity. 

At  or  near  term  uterine  contractions,  called  spurious  labor,  occur  and 
this  spurious  labor  is  a  time  of  great  danger  alike  to  the  mother  and  the 
fetus.  To  the  mother  for  the  reason  that  the  uterine  contractions  have 
in  a  number  of  instances  caused  a  rupture  of  the  gestation  sac  resulting 
in  maternal  death.  To  the  child  because  even  without  rupture  of  the 
gestation  sac  the  uterine  contractions  may  so  interfere  with  the  placental 
circulation  as  to  kill  the  fetus.  This  occurred  in  one  of  the  author's 
cases  in  which,  although  the  fetus  was  alive  when  he  was  sent  for  to 
operate,  in  the  twenty-four  hours  intervening  before  he  could  reach  the 
case  the  uterine  contractions  had  so  interfered  with  the  placental  circula- 
tion as  to  kill  the  fetus. 

The  diagnosis  of  advanced  ectopic  gestation  is  one  which  is  often  over- 
looked and  in  many  cases  is  difficult.  The  three  features  which  stand 
out  as  guide-posts  to  the  diagnosis  are : 

1.  The  history  of  an  occurrence  somewhat  resembling  a  miscarriage 
followed  by  pelvic  inflammation  in  the  course  of  what  otherwise  seemed  a 
normal  pregnancy. 

2.  The  physical  signs  of  a  fetus  lying  nearer  than  normal  to  the 
abdominal  wall,  with  fetal  movements  very  distinct  and  easily  palpable, 
as  though  just  beneath  the  skin. 

3.  Finding  the  uterus  small,  empty  and  separate  from  the  gestation 
sac. 

The  author  is  free  to  admit  that  in  two  of  his  cases  he  was  unable 
to  make  the  positive  diagnosis  of  ectopic  gestation  until  he  had  anes- 
thetized the  woman  and  introduced  his  finger  into  the  cervical  canal  and 
thus  proved  the  uterus  empty.  The  reasons  for  the  difficulties  in  diag- 
nosis are  obvious.  The  landmarks  of  the  pelvic  organs  are  largely 
obscured  by  inflammatory  adhesions  binding  them  together.  The  uterus 
is  often  closely  incorporated  with  the  gestation  sac  and  seems  practi- 
cally a  part  of  it. 

Thus  it  is  that  the  correct  diagnosis  is  sometimes  overlooked  until 
spurious  labor  calls  attention  to  the  fact  that  the  conditions  are  abnormal. 

Treatment  of  Ectopic  Gestation. — In  discussing  the  treatment  of  ectopic 
gestation  the  author  prefers  to  divide  the  subject  into  two  periods:— ^ 

(a)  Early  ectopic  gestation  (under  six  months). 

(b)  Advanced  ectopic  gestation. 


552    ECTOPIC  GESTATION— PREGNAA'CY  IN   MALFORMED    UTERI 

The  reason  for  incliidin<i;  gestation  as  late  as  the  sixth  month  in  the 
period  of  early  ectopic  gestation  is  that,  in  the  author's  judgement,  up 
to  this  time  the  life  of  the  fetus  should  be  disregarded  and  therefore  the 
same  principles  of  treatment  apply. 

Treatment  of  Early  Ectopic  Gestation. — This  again  may  be 
considered  under  three  heads: 

(a)  Prior  to  tubal  rupture  or  abortion. 

(b)  At  the  time  of  tubal  rupture  or  abortion. 

(c)  Subsequent  to  tubal  rupture  or  abortion. 

Prior  to  Tubal  Rupture  or  Abortion. — As  soon  as  the  diagnosis  of 
unruptured  ectopic  gestation  is  positively  made  there  can  be  but  one 
wise  indication,  i.  e.,  removal  of  the  pregnant  tube  by  operation. 

Methods  Formerly  in  Vogue. — Attempts  to  kill  the  fetus  by  electricity 
or  by  the  injection  of  morphin  or  other  substances  in  the  hope  that 
the  pregnancy  will  l)e  arrested  and  operation  avoided  have  now  been 
abandoned  as  uncertain,  unsafe,  and  unjustifiable. 

Even  after  the  death  of  the  fetus,  as  long  as  the  tube  is  not  emptied, 
hemorrhages  into  it  may  occur,  causing  rupture  of  the  tube  with  all  its 
possible  dangers.  Furthermore,  it  can  never  be  told  when  tubal  rupture 
or  abortion  is  to  occur  or  whether  this  occurrence  is  to  have  a  fatal  issue 
or  not.  These  accidents  may  occur  during  the  course  of  treatment  which 
seeks  to  kill  the  fetus.  The  only  safe  rule  to  follow  is  to  save  the  woman 
the  risks  accompanying  tubal  rupture  and  abortion  by  removing  the 
pregnant  tube.  As  a  rule  this  operation  is  better  done  by  the  abdominal 
than  by  the  ^■aginal  route,  as  by  the  former,  with  the  pehic  organs  in 
good  view,  such  conservative  work  as  may  be  necessary  to  leave  them  in 
good  condition  for  the  future  may  be  done.  The  risk  in  the  operation 
for  removal  of  an  unruptured  tube  in  the  hands  of  one  accustomed  to 
abdominal  work  is  very  slight  and  is  as  nothing  compared  to  that  to 
which  the  woman  is  exposed  if  left  to  the  possible  dangers  of  tubal  rupture 
or  abortion. 

At  the  Time  of  Tubal  Rupture  or  Abortion. — The  condition  is  that  of 
a  woman  suffering  from  internal  hemorrhage  and  shock,  and  the  iatter 
is  largely  dependent  upon  the  former.  If  the  tube  has  ruptured  the 
hemorrhage  may  continue  until  the  death  of  the  woman.  If  tubal  abor- 
tion has  occurred  and  is  complete  the  hemorrhage  may  cease  without 
fatal  issue,  but  if  incomplete,  and  as  already  stated,  according  to  Wormser 
the  incomplete  tubal  abortions  are  ten  times  as  frequent  as  the  complete, 
the  hemorrhage  may  continue  or  be  repeated  until  the  woman  is  exsan- 
guinated. For  these  reasons  the  author  has  adopted  for  his  own  guidance 
the  following  rule: 

If  the  patient  is  seen  at  the  time  of  tubal  rupture  or  abortion,  operate 
and  check  the  hemorrhage  as  soon  as  careful  preparations  for  the  opera- 
tions can  be  made,  unless  the  patient  is  in  such  extreme  collapse  that  the 
operation  in  itself  would  probably  prove  fatal.  In  this  case  watch  the 
patient  carefully,  noting  the  condition  ot  the  pulse  at  short  intervals, 
to  see  if  the  patient  is  impro\ing  or  losing  ground.  If  improving,  wait 
and  operate  when  the  patient  is  in  better  condition.    If  losing  ground, 


ECTOPIC  GESTATION  553 

operate  rapidly,  seeking  to  check  the  hemorrhage  with  as  Httle  manipu- 
lation as  possible,  perhaps  having  an  assistant  infuse  the  patient  during 
the  operation,  and  leaving  considerable  warm  salt  solution  in  the  abdomen 
when  closing  it.  Regarding  the  details  of  the  operation  for  ruptured 
ectopic  gestation  something  may  well  be  said.  At  the  time  of  tubal 
rupture  or  abortion  the  operation  is  much  better  done  from  above  than 
from  below.  The  bleeding-point  is  much  more  easily  found  and  secured 
through  the  abdominal  incision  than  through  the  vaginal  route  and  for 
the  subsequent  steps  of  the  operation:  removing  the  gestation  sac,  blood- 
clots,  etc.,  the  abdominal  route  is  certainly  preferable. 

In  making  the  abdominal  incision,  passing  through  the  fascia  and  ap- 
proaching the  peritoneum,  the  latter  usually  appears  darker  than  normal 
and  bulging.  "With  the  nicking  of  the  peritoneum  the  blood  usually  gushes 
out  and  if  any  doubts  of  diagnosis  existed  before,  they  are  now  dissipated. 

In  planning  the  operation  for  ruptured  ectopic  gestation  it  is  well  to  bear 
in  mind  the  fact  that  the  field  of  the  lesion,  and  therefore  the  field  of  the 
operation,  is  supplied  by  two  arteries  (see  Fig.  31),  the  ovarian  coming 
in  at  the  upper  part  of  the  broad  ligament  and  the  uterine  entering  the 
broad  ligament  at  its  lower  portion,  then  coursing  up  along  the  side  of 
the  uterus  to  anastomose  with  the  ovarian  artery  near  the  uterine  cornu. 
The  hemorrhage  in  the  patient  before  us  must  come  from  one  or  both  of 
these  arteries,  hence  a  ligature  or  clamp  about  the  tube  near  the  horn  of 
the  uterus  and  another  about  the  upper  portion  of  the  infundibulopelvic 
ligament  just  distal  to  the  fimbriated  extremity  of  the  tube  will  control 
the  ordinary  sources  of  bleeding. 

The  reason  for  calling  attention  to  these  vessels  rests  in  the  fact  that 
often  the  abdomen  is  full  of  blood ;  the  pelvic  field  is  completely  obscured 
by  it,  and  unless  the  operator  has  distinctly  in  mind  what  he  has  to  do, 
much  valuable  time  may  be  wasted  in  sponging  away  blood  which  has 
already  been  lost  without  checking  its  source. 

First  determine  on  which  side  the  gestation  sac  lies,  seize  the  broad 
ligament  and  tube  near  the  horn  of  the  uterus  on  that  side  and  draw  it 
into  view.  The  compression  with  the  thumb  and  finger  at  this  point 
will,  in  a  large  number  of  cases,  check  the  hemorrhage,  as  the  bleeding  at 
the  point  of  rupture  is  apt  to  come  from  the  uterine  end  of  the  tube.  iVt 
any  rate  the  situation  is  now  under  control;  the  ligatures  can  be  placed 
as  desired  and  the  hemorrhage  is  checked.  As  a  rule  the  affected  tube 
should  be  removed  as  a  probable  source  of  future  trouble  even  if  the 
case  is  one  of  abortion  rather  than  rupture.  Some  operators  (^Martin, 
Prochownich  and  others)  advocate  leaving  the  tube  in  certain  cases  of 
tubal  abortion  even  if  it  has  to  be  incised  to  remove  the  product  of 
conception.  The  removal  of  the  tube  is,  in  the  opinion  of  the  author, 
a  much  safer  procedure. 

The  removal  of  the  blood-clots  should  now  receive  attention.  After 
scooping  out  the  larger  ones  with  the  hand,  the  remainder  can  best  be 
flushed  out  with  warm  salt  solution,  it  being  borne  in  mind  that  it  is  not 
necessary  to  remove  every  small  clot  and  that  more  harm  may  be  done 
by  prolonging  the  operation  than  benefit  derived  from  removing  the  clot. 


554    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

The  warm  salt  solution  will  often  stimulate  the  patient  and  if  the  opera- 
tion is  (lone  quickly,  carefully  and  with  as  little  handlino;  of  the  intestines 
as  possible,  cases  which  seemed  almost  hopeless  will  often  stand  the 
oj)eration  well  and  begin  to  rally  as  soon  as  the  hemorrhage  is  checked 
and  the  blood-clots  removed. 

\Yhen  operating  at  the  time  of  tubal  rupture  or  abortion  the  abdominal 
wound  should  be  closed  without  drainage.  The  field  of  operation  is  a 
clean  one.  The  blood-clots  are  aseptic  and  the  risks  of  infection  are  less 
without  than  with  drainage. 

In  the  interstitial  variety  of  ectopic  gestation,  as  has  already  been  said, 
the  pregnancy  advances  further  before  rupture,  the  muscular  wall  about 
the  ovum  is  thicker  and  more  vascular  and  its  rupture  is  naturally 
attended  by  more  hemorrhage  and  shock.  It  can  easily  be  seen  that 
this  is  the  variety  of  ectopic  gestation  most  likely  to  be  rapidly  fatal  at 
the  time  of  rupture.  The  first  steps  of  the  operation  are  the  same  as 
those  indicated  above:  Open  the  abdomen,  seize  with  thumb  and  fingers 
the  broad  ligament  and  the  tube  near  the  horn  of  the  uterus  on  the  side 
occupied  by  the  gestation  sac  and  draw  it  into  view.  While  in  this  variety 
it  may  occasionally  be  possible  to  excise  the  aft'ected  uterine  cornu  and 
leave  the  uterus,  in  the  majority  of  cases  it  is  safer  to  remove  the  uterus. 
The  peritoneal  cavity  is  then  cleansed  of  blood-clots  and  products  of 
gestation  and  the  abdominal  wound  closed. 

In  the  above  description  of  the  treatment  at  the  time  of  tubal  rupture 
or  abortion  the  conditions  considered  have  been  those  of  intraperitoneal 
escape  of  the  ovum.  Occasionally,  as  previously  indicated,  the  rupture 
takes  place  through  the  floor  of  the  tube  down  between  the  folds  of  the 
broad  ligament.  In  this  variety  of  intraligamentous  rupture  of  early 
ectopic  gestation  an  exception  may  be  made  to  the  rule — operate  at  the 
time  of  rupture.  If  the  diagnosis  is  clear  and  the  hemorrhage  evidently 
extraperitoneal  and  encapsulated,  pushing  the  uterus  upward,  forward 
and  to  the  opposite  side,  operation  may  be  postponed  while  the  patient 
is  kept  under  close  observation.  The  two  indications  for  operation 
which  should  be  constantly  kept  in  mind  are  repeated  hemorrhage 
and  suppuration.  Often  the  pelvic  hematoma  produced  by  the  intra- 
ligamentous rupture  will  be  gradually  absorbed  and  no  other  treatment 
needed  save  rest  in  bed  and  the  ice-bag  upon  the  lower  abdomen  during 
the  first  few  hours  following  the  rupture.  Occasionally,  however,  due 
to  the  erosion  of  the  trophoblastic  layer  of  the  chorion,  new  vessels  are 
opened  and  fresh  hemorrhage  occurs  to  the  extent  sometimes  of  causing 
rupture  through  the  broad  ligament  fold  into  the  peritoneal  cavity.  In 
these  instances  of  recurrent  hemorrhage  in  an  intraligamentous  rupture 
it  is  wiser  to  open  the  abdomen  and  seek  the  source  of  bleeding  from 
above  rather  than  to  attempt  to  deal  with  it  through  a  vaginal 
incision. 

Another  termination  of  an  intraligamentous  rupture  is  that  of  suppura- 
tion of  the  hematoma.  Although  the  blood-clots  are  aseptic  at  the  time 
of  the  formation  of  the  hematoma,  the  close  proximity  of  the  rectum 
makes  infection  easy  and  not  at  all  infrequent.    It  is  here  m  the  treat- 


ECTOPIC  GESTATION  555 

ment  of  a  suppurating  intraligamentous  hematoma  that  the  vaginal 
incision  and  drainage  is  the  operation  of  choice. 

Treatment  of  Early  Ectopic  Gestation  Siibsegnent  to  Tubal  Rupture  or 
Ahortio7i. — It  not  infrequently  happens  that  th^obstetric  surgeonyfirst 
sees  the  case  of  ectopic  gestation  several  days  or  weeks  after  the  escape 
of  the  ovum  from  the  tube  either  intraperitoneally  or  extraperitoneally. 

If  the  escape  has  been  intraperitoneal  and  the  physical  signs  of  a  pelvic 
hematocele  with  the  boggy  feel  of  blood-clots  behind  and  to  the  side  of 
the  uterus  are  detected,  operation  and  removal  of  the  blood- clots,  gesta- 
tion products  and  probably  the  tube  is,  as  a  rule,  the  indication,  for  it  is 
usually  impossible  to  tell  whether  the  tube  is  emptied  or  whether  villi 
still  remaining  are  to  erode  and  open  other  vessels  with  hemorrhage 
which  may  be  disastrous.  Here  again,  unless  the  hematocele  has  sup- 
purated, the  abdominal  operation  is  preferred  to  the  vaginal.  If  suppura- 
tion has  occurred  vaginal  incision  and  drainage  are  indicated.  If  the 
rupture  was  intraligamentous  and  not  seen  until  some  time  subsequent 
to  its  occurrence,  the  same  rules  hold  for  observation  or  operation  as 
already  given  when  discussing  the  treatment  of  ectopic  gestation  at  the 
time  of  intraligamentous  rupture,  viz.,  operate  only  if  hemorrhages  recur 
or  the  hematoma  suppurates.  Before  leaving  the  subject  of  the  treatment 
of  the  early  ectopic  gestation  the  question  may  well  be  asked :  Is  it  never 
safe  to  leave  a  case  of  tubal  abortion  without  operation?  Undoubtedly 
many  patients  have  suffered  from  tubal  abortion  in  which  the  tube 
emptied  itself  completely  and  recovery  followed  without  operation.  It 
is  never  safe  to  make  this  prognosis.  If  the  patient  is  seen  near  the 
time  of  the  occurrence  of  the  tubal  abortion,  the  difficulties  in  the  way  of 
determining  that  the  tube  is  empty  are  so  great  that  the  author  believes 
it  unsafe  to  advise  non-interference.  On  the  other  hand,  in  a  few  cases 
not  seen  until  a  considerable  time  has  elapsed  since  the  tubal  abortion, 
in  which  the  history  has  shown  no  recurrence  of  the  hemorrhage  since 
the  first,  and  in  which  the  tube  has  felt  to  him  empty  and  the  hemato- 
cele firm  and  diminishing  in  size,  he  has  advised  non-interference  without 
regret. 

Treatment  of  Advanced  Ectopic  Gestation. — When  the  ectopic 
gestation  has  advanced  to  a  development  of  six  months  a  different  phase 
of  the  subject  is  presented.  Two  lives  come  into  consideration:  the  fetal 
as  well  as  the  maternal.  Up  to  this  period  of  fetal  development,  although 
admitting  that  this  period  is  arbitrarily  selected,  the  author  believes 
the  fetal  life  should  be  disregarded.  Now  as  pregnancy  reaches  six 
months  of  advancement  and  the  fetus  begins  to  make  its  presence  more 
evident,  two  questions  present  themselves: 

1.  Is  the  fetus  worth  saving  if  pregnancy  continues  till  the  child  is 
viable  and  is  delivered  alive? 

2.  Is  the  maternal  risk  greatly  increased  by  allowing  the  gestation  to 
continue  from  six  to  eight  and  a  half  months? 

In  answering  the  first  question  the  author's  experience  is  of  value. 
It  has  been  his  fortune  to  operate  upon  6  cases  of  advanced  ectopic 
gestation.    In  3  the  child  was  alive  at  the  time  of  operation  and  all 


556    ECTOPIC  GESTATION— PREGNAXCY  IX  MALFORMED   UTERI 

3  of  the  children  left  the  hospital  in  good  condition  with  their  mothers 
at  the  ex])iration  of  their  period  of  convalescence. 

In  one  of  the  li\"ino;  children  there  was  a  congenital  dislocation  of  the  hip, 
yet  otherwise  the  child  was  healthy.  In  another  of  the  living  children, 
one  foot  was  everted,  the  other  inverted  at  time  of  birth,  but  at  three 
months  under  non-operative  orthopedic  treatment  the  feet  and  legs  were 
practically  straight  (see  Fig.  350).  The  remaining  4  children  seemed 
perfectly  formed.  These  children  seemed  certainly  worth  saving,  provided 
the  risk  to  the  mother  was  not  greatly  increased  thereby. 

It  is  generally  recognized  that  at  about  term  spurious  labor  is  apt  to 
intervene  and  this  spurious  labor  in  a  number  of  instances  has  caused 


Fig.  350. — Full-term  child;    ectopic  gestation. 


rupture  of  the  ge.station  sac  and  maternal  death.  However,  the  author's 
experience  and  study  of  the  literature  would  seem  to  teach  that  if  this 
time  of  spurious  labor  is  anticipated  and  the  gestation  terminated  at 
eight  and  one-half  months,  the  risk  to  the  mother  has  been  but  little 
increased  by  this  wait  of  two  and  a  half  months.  It  therefore  seems 
justifiable  in  dealing  with  cases  of  ectopic  gestation  which  have  advanced 
to  six  months  or  later  to  give  the  life  of  the  child  consideration,  and 
endeavor  to  secure  a  viable  child  by  allowing  the  pregnancy  to  approach 
term  but,  realizing  the  danger  of  spurious  labor  to  both  mother  anrl  child, 
avoid  this  risk  by  operating  at  about  eight  and  a  half  months.  Another 
apparent  advantage  in  avoiding  the  last  two  weeks  of  gestation  rests 


ECTOPIC  GESTATION  557 

in  the  fact  that  in  the  last  two  weeks  the  relative  amount  of  liquor  amnii 
seems  lessened  and  the  fetus  is  subjected  to  more  pressure. 

Operation  for  Advanced  Ectoinc  Gestation. — The  crux  of  the  whole 
matter  in  dealing  by  operation  with  cases  of  advanced  ectopic  gestation 
lies  in  the  management  of  the  placenta.  In  the  intraligamentous  variety 
the  placenta  is  often  spread  out  over  the  whole  side  of  the  pelvic  floor  and 
firmly  adherent  to  the  pelvic  vessels,  and  in  the  intraperitoneal  variety 
the  placenta  may  be  just  as  firmly  adherent  to  the  intestines  and  practi- 
calh'  any  of  the  abdominal  viscera.  To  separate  from  its  bed  a  placenta 
thus  firmly  adherent,  with  the  fetal  circulation  of  it  active  until  the  cord  is 
tied,  and  with  the  chorionic  villi  imbedded  as  they  often  are,  may  mean 
so  profuse  a  hemorrhage  as  to  cause  the  loss  of  the  patient  on  the  table. 
For  this  reason  it  is  found  wiser,  save  in  those  exceptional  cases  where 
careful  examination  of  the  sac  shows  that  the  vessels  supplying  it  can 
be  hgated  and  the  sac  removed  entire,  to  remove  the  fetus  only  and  leave 
the  placenta  to  separate  gradually  and  come  away. 

In  a  large  number  of  cases  of  advanced  ectopic  gestation,  as  already 
stated,  the  rupture  occurs  downward  through  the  floor  of  the  tube  and 
the  development  is  intraligamentous. 

In  these  cases  the  peritoneum  is  lifted  from  the  floor  of  the  pelvis  and 
even  from  the  abdominal  wall,  so  that  an  abdominal  incision  at  the  outer 
border  of  the  rectus  muscle  will  sometimes  open  into  the  gestation  sac 
without  opening  the  general  peritoneal  ca^'ity.  If  the  placenta  has  to 
be  left  to  come  away  piecemeal  it  is  a  distinct  advantage  to  have  the 
peritoneum  unopened,  hence  the  author's  custom  is  to  make  a  lateral 
rather  than  a  median  incision.  Having  reached  the  sac,  the  wisest  plan 
is  first  to  examine  its  surrovnidings  carefully  to  determine  whether  the 
attachment  of  the  placenta  is  such  that  the  vessels  supplying  the  sac 
can  be  ligated  and  the  sac  safely  removed.  If  the  gestation  is  of  the 
tubo-abdominal  variety  this  can  often  be  done,  as  in  one  of  the  author's 
cases,  and  the  abdominal  wound  closed  and  the  period  of  convalescence 
greatly  shortened. 

On  the  other  hand,  the  decision  to  attempt  to  remove  the  sac  must 
be  carefully  made,  as  once  the  removal  is  started  it  is  often  necessary  to 
complete  it  even  at  the  risk  of  great  loss  of  blood.  Under  ordinary 
circumstances  the  safest  plan  of  treatment  is  to  incise  the  gestation  sac; 
remove  the  child;  stitch  the  sac  to  the  abdominal  wound  and  pack  the 
sac  with  a  weak  iodoform  gauze.  This  packing  can  be  changed  every 
second  or  third  day  and  the  separation  of  the  placenta  aided  with  the 
finger.  A  sinus  will  persist  for  a  time  after  the  separation  of  the  placenta, 
but  in  all  of  the  author's  cases  the  sinus  closed  in  a  reasonably  short 
time.  Catgut  should  be  the  ligature  and  suture  material  employed,  as 
otherwise  the  sinus  would  probably  persist  longer. 

In  the  above  discussion  of  treatment  by  operation  it  has  been  under- 
stood that  the  fetus  was  alive  at  the  time  of  operation.  If  the  fetus 
has  been  dead  for  a  month  or  more  and  the  sac  not  infected,  the  operation 
is  simpler  for  the  reason  that  the  placenta  separates  much  more  easily 
and  there  is  not  the  danger  of  profuse  hemorrhage  from  the  site  of  the 


558    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED    UTERI 

placental  attachment.  In  fact,  the  rule  is  to  remove  the  placenta  as 
distinguished  from  the  case  with  a  living  fetus,  where  the  rule  is  to 
leave  it. 

The  question  now  presents  itself:  Given  a  case  of  advanced  ectopic 
gestation  in  which  the  fetus  has  just  died,  is  it  wiser  to  operate  at  once  or 
later?  Eealizing  that  the  placenta  can  be  removed  more  easily  and 
safely  a  few  weeks  later,  it  is  usually  wise  to  postpone  the  operation  from 
four  to  six  weeks  to  allow  for  some  obliteration  of  the  maternal  blood 
spaces  about  the  chorionic  villi  of  the  placenta.  During  this  time,  how- 
ever, the  woman  should  be  under  careful  observation,  and  if  any  evi- 
dence of  infection  occurs,  as  shown  by  her  temperature  or  pulse,  prompt 
operation  is  indicated. 

With  a  living  fetus,  and  also  with  a  dead  fetus,  if  the  gestation  sac  is 
.not  infected,  the  abdominal  operation  is  the  method  of  choice. 

On  the  other  hand,  if  the  gestation  sac  has  suppurated  the  vaginal 
operation  allowing  for  the  removal  of  the  gestation  products  and  drain- 
age is  preferable.  In  removing  the  gestation  sac  in  the  abdominal  opera- 
tion it  is  sometimes  found,  especially  in  the  intraligamentous  variety, 
that  the  uteru,s  is  so  incorporated  with  the  sac  that  the  operation  is  best 
completed  with  a  hysterectomy. 


PREGNANCY  IN  MALFORMED  UTERI. 

When  considering  the  varieties  of  malformation  of  the  uterus  which 
would  cause  trouble  during  pregnancy,  it  must  be  remembered  that 
malformations  of  the  uterus  and  vagina  are  dependent  chiefly  upon  some 
fault  in  the  normal  development  and  fusion  of  the  ducts  of  INIiiller.  In 
the  normal  course  of  development  the  upper  portions  of  the  ducts  of 
Miiller,  although  separate,  converge,  forming  the  Fallopian  tubes;  the 
middle  portions  fuse  and  the  partitions  between  them  disappear,  forming 
the  uterus,  while  their  lower  portions  by  a  similar  fusion  and  absorption 
of  partition  form  the  vagina.  Any  interruption  in  this  normal  fusion 
and  development  may  leave  more  or  less  of  a  double  canal  in  the  uterus 
or  in  the  vagina,  and  depending  on  the  equality  or  inequality  in  the 
development  of  the  two  halves,  there  may  result  either  a  symmetrical 
double  uterus  and  vagina  or  one-half  may  be  well  developed  while  the 
other  presents  all  grades  of  development  from  zero  to  perfection. 

As  pregnancy  in  malformed  uteri  is  only  being  considered,  those  rare 
conditions  of  absence  of  the  uterus  and  rudimentary  uterus  in  which  the 
latter  organ  is  represented  only  by  a  band  of  connective  tissue  posterior 
to  the  bladder  need  not  be  discussed.  For  pregnancy  to  exist  at  least  one 
of  the  ducts  of  INIiiller  must  have  developed  sufficiently  to  form  a  service- 
able half  of  a  double  uterus  and  vagina. 

The  varieties  of  malformation  then  which  concern  the  obstetrician  are: 

1.  The  uterus  unicornis  (see  Fig.  351),  in  which  only  one  duct  of  Miiller 
is  developed. 


PREGNANCY  IN  MALFORMED   UTERI 


559 


2.  The  uterus  bicornis  in  its  various  forms  (see  Figs.  352,  353,  and  354), 
in  which  both  ducts  are  equally  developed  but  there  is  a  fault  in  the 
normal  fusion  and  absorption. 


Fig.  351. — Uterus  unicornis:     LH,  left  horn;  LT,  left  tube;  Lo,  left  ovary;  RH,  right 
horn;  RT,  right  tube;  Ro,  right  ovary;  RLr,  right  round  ligament;  LLr,  left  round  ligament. 

(Mann.) 

3.  The  uterus  bicornis  in  which  one  duct  is  imperfectly  developed  and 
has  no  communication  with  the  vagina  (see  Fig.  355). 

4.  The  uterus  didelphys  (see  Fig.  356)   in  which  the  two  halves  are 
separate  throughout. 


Fig.  352. — Uterus  bicornis. 


5.  The  uterus  septus  (see  Fig.  357)  in  which  the  exterior  of  the  uterus 
feels  normal  but  the  partition  between  the  middle  portions  of  the  ducts 
of  Miiller  has  never  absorbed. 


500    ECTOPIC  GESTATION— PREGNANCY  IN   MALFORMED   UTERI 

G.  The  uterus  bipartitus  (see  Fig.  358)  in  which  both  uterus  and  vagina 
are  doulile  and  lie  side  by  side  as  separate  tubes.    And  lastly 

7.  The  double  vagina  in  which  the  fusion,  absorption  and  develop- 
ment of  the  ducts  of  Miiller  are  normal  until  the  vagina  is  reached,  but 


Fig.  .35-3. — Uterus  cordiformis:  a,  indented  fundus;  h,  b,  tubes;  c,  c,  round  ligaments; 
d,  central  longitudinal  ridge  on  posterior  wall  of  uterine  cavity;  e,  e,  lateral  ridges  of  same; 
/,  internal  os;  g,  g,  cervix.     (Hirst.) 


Fig.  354. — Uterus  incudiformis.     (Hirst.) 


Fig.  35.5. — Uterus  bicoruis  unicollis  with  rudimentary  horn.     (Kehrcr.) 

here  a  partition  is  left  dividing  the  vagina  throughout  more  or  less  of 
its  strength. 

^Yhile  all  of  these  malformations  may  cause  confusion  in  diagnosis 
both  in  pregnancy  and  in  labor,  and  several  of  them  may  cause  com- 


PREGNANCY  IN  MALFORMED   UTERI 


561 


Fig.  356. — Double  uterus  (uterus  didelphys) :  a,  right  cavity;  b,  left  cavity;  c,  right 
ovary;  d,  right  round  ligament;  e,  left  round  ligament;  /,  left  tube;;?,  left  vaginal  portion; 
h,  right  vaginal  portion;  i,  right  vagina;  /,  left  vagina;  k,  partition  between  the  two  vaginse. 
(Mann.) 


Fig.  357. — Uterus  septus  duplex  (natural  size),  completely  double  uterus,  and  incom- 
pletely double  vagina  of  a  girl,  aged  twenty-two  years:  a,  a,  tubes;  b,  b,  fundus  of  the  double 
uterus;  c,  c,  c,  partition  of  uterus;  d,  d,  cavities  of  the  uterine  bodies;  e,  e,  internal  orifices; 
/, /,  external  walls  ofjthe  two  necks;  g,  g,  external  orifices;  h,  h,  vaginal  canals;  ^,  partition 
which  divided  the  upper  third  of  the  vagina  into  two  halves.  (Mann.) 
36 


502    ECTOPIC  GESTATION— PREGNANCY  IN  MALFORMED   UTERI 

plications  of  labor  which  will  be  discussed  later,  the  only  variety  which 
is  likely  to  cause  pathological  pregnancy  and  deserves  to  be  studied  in 
connection  with  the  preceding  section  on  ectopic  gestation  is  that  in 
which  one  of  the  ducts  of  Miiller  is  rudimentary  and,  although  its  Fallo- 
pian tube  and  uterine  body  are  patent,  has  no  communication  with 
either  the  cervical  canal  or  vagina  (see  Fig.  355).  Here  by  external 
migration  of  the  ovum  from  the  opposite  ovary,  or  by  external  migra- 
tion of   spermatozoa  from  the   opposite  tube  impregnating  an  ovum 


Fig.  358. — Uterus  bicoruis  duplex:  o,  a,  double  entrance  to  vagina;  b,  meatus  urinarius; 
c,  clitoris;  d,  urethra;  e,  e,  double  vagina;  /,  /,  external  orifices  of  uterus;  (j,  g,  double  cervix; 
h,  h,  bodies  and  horns  of  uterus;  i,  i,  ovaries;  k,  k,  tubes;  I,  I,  round  ligaments;  ni,  m,  broad 
ligaments.      (Hirst.) 


from  the  ovary  of  the  affected  side,  a  pregnancy  may  start  in  this  rudi- 
mentary horn.  As  there  is  no  communication  with  the  cervical  canal 
or  vagina,  the  natural  result  is  rupture  with  all  the  dangers  of  fatal 
intraperitoneal  hemorrhage  which  is  associated  with  interstitial  ectopic 
gestation.  This  rupture  usually  occurs  during  the  first  four  months. 
Occasionally  the  fetus  is  retained  for  an  indefinite  period  in  the  rudimen- 
tary liorn  as  a  lithopedion,  or  is  eliminated  by  suppuration. 

Treatment. — If  the  diagnosis  is  made  prior  to  rupture  of  the  sac  abdom- 
inal section  should  be  performed  and  the  pregnant  rudimentary  horn 
removed.    Unfortunately,  however,  in  such  cases,  as  in  that  of  interstitial 


PREGNANCY  IN  MALFORMED   UTERI  563 

ectopic  gestation,  the  first  intimation  of  the  condition  is  often  at  the  time 
of  rupture,  with  its  chnical  picture  of  internal  hemorrhage  and  collapse. 
The  treatment  indicated  is  removal  of  the  pregnant  horn  or  hysterectomy, 
depending  upon  the  conditions  found  at  operation. 

Pregnancy  in  a  uterus  unicornis  and  in  a  uterus  bicornis  with  both  horns 
having  a  communication  with  the  cervical  canal  and  vagina  usually 
progresses  normally,  but  there  are  several  interesting  features  of  preg- 
nancy in  the  different  forms  of  double  uterus  which  deserves  consid- 
eration. 

The  unimpregnated  half  undergoes  a  sympathetic  hypertrophy  and 
develops  a  decidua  as  does  the  other.  If  the  unimpregnated  half  has  a 
communication  with  the  cervical  canal  and  vagina,  this  decidua  may  be 
discharged  with  a  metrorrhagia  presenting  the  clinical  picture  of  a  mis- 
carriage as  happened  in  a  case  seen  by  the  author  in  consultation. 

Under  these  circumstances  the  continuation  of  pregnancy  after  a  sup- 
posed miscarriage  may  lead  to  considerable  surprise. 

In  the  case  above  referred  to  there  occurred  at  irregular  intervals 
during  the  pregnancy  a  moderate  bloody  discharge,  apparently  a  men- 
struation from  the  unimpregnated  half  of  the  uterus. 

Pregnancy  in  a  uterus  bicornis  may  give  rise  to  various  doubts  in 
diagnosis  as  to  the  contents  of  each  horn  and  the  diagnosis  perhaps 
absolutely  cleared  only  at  the  termination  of  labor.  In  one  of  the  author's 
cases  the  placenta  was  situated  in  one  horn  and  the  fetus  in  the  other; 
the  horn  containing  the  placenta  presenting  much  the  feel  of  a  soft 
fibromyoma.  In  rare  instances  of  twin  pregnancy  in  a  uterus  bicornis 
one  twin  has  been  found  in  each  horn.  Dystocia  arising  from  different 
forms  of  malformed  uteri  is  discussed  under  the  head  of  Dystocia  (see 
page  625). 


CHAPTER  XVII. 
HEISIORRHAGE. 

One  of  the  most  important  complications  of  pregnancy,  labor  and  the 
puerperium  is  hemorrhage,  and  it  will  be  discussed  as  occurring  in  each 
of  these  three  periods. 

Etiology. — Hemorrhage  during  and  immediately  following  lal)or  may 
result  from  laceration  of  some  portion  of  the  parturient  canal,  but  the 
chief  factor  in  obstetric  hemorrhage  is  the  placenta,  the  hemorrhage 
resulting  from  the  opening  of  the  uteroplacental  vessels  and  insufficient 
uterine  contractions  to  close  the  uterine  sinuses. 

Varieties. — Mewing  hemorrhage  as  either  antepartum,  intrapartum 
or  postpartum,  the  following  classification  will  be  adopted,  based  on  its 
etiology. 

Hemorrhage, 
axtepartum  from  ixtrapartum  from  postpartum. 

1.  Al^normally     situated  1.  Abnormally     situated  1.   The    so-called    postpar- 

placcnta.  placenta.  tiun  hemorrhage. 

2.  Normally  situated  pla-         2.   Normally  situated  pla-         2.   Puerperal  hemorrhages. 

cent  a.  cent  a. 

3.  .\bnormally      situated         .3.  Lacerations. 

placenta  and   fetus 
(ectopic  gestation). 

In  studying  ante])artiun  hemorrhage  or  that  occurring  during  i)reg- 
nancy,  the  first  variety  presenting  itself  for  consideration  is  that  from 
an  abnormally  situated  placenta,  and  the  first  example  of  this  to  be 
studied  is  placenta  previa. 


PLACENTA  PREVIA. 

Placenta  pre\ia  is  a  ])lacenta  situated  wholly  or  in  part  in  the  lower 
uterine  segment,  that  part  of  the  uterus  which  dilates  as  labor  advances. 

Varieties. — Several  ^■a^ieties  of  placenta  previa  are  recognized  accord- 
ing to  the  situation  of  the  placenta  in  the  lower  uterine  segment,  thus 
placenta  previa  may  be  complete  or  incomplete. 

A  complete  placenta  previa  is  one  in  which  the  j)lacenta  completely 
covers  the  internal  os  (see  Fig.  359). 

An  incomplete  placenta  previa  is  one  in  which  the  placenta  does  not 
completely  cover  the  internal  os. 

It  may  be  partial,  overlapping  the  internal  os  (see  Fig.  360),  marginal, 
just  reaching  the  internal  os  (see  Fig.  361),  or  lateral,  lying  in  the  lower 
uterine  segment,  but  not  reaching  the  internal  os  (see  Fig.  362). 
(564) 


PLACENTA   PREVIA  565 

Frequency. — The  frequency  of  placenta  previa  is  much  greater  in  a 
maternity  hospital  than  in  private  practice  for  the  reason  that  many 
cases,  which  if  normal  would  have  been  treated  at  home,  are  sent  to  the 
hospital  on  account  of  the  complication.  Moreover,  the  statements  by 
different  authors  regarding  the  frequency  of  the  condition  vary  greatly, 
Tarnier  giving  the  frequency  as  once  in  207  cases,  and  W.  Miiller  as 
once  in  1078  cases. 


Fig.  359. — Complete  placenta  previa.  Fig.  .360. — Partial  placenta  previa. 

According  to  the  author's  experience  placenta  previa  in  an  active 
hospital  maternity  service  occurs  with  greater  frequency  than  is  repre- 
sented even  by  Tarnier's  figures,  and  in  private  practice  once  in  500  cases 
represents  the  frequency  more  closely  than  do  the  figures  of  Miiller. 

In  25,000  consecutive  deliveries  at  the  Sloane  Hospital  there  were 
223  cases  of  placenta  previa,  giving  a  frequency  of  once  in  112  cases. 


Fig.  361. — Marginal  placenta  previa.  Fig.  362. — Lateral  placenta  previa. 

The  frequency  of  the  complete  variety  is  much  less  than  of  the  incom- 
plete. In  174  cases  occurring  in  20,000  consecutive  deliveries  at  the 
Sloane  Hospital  there  were  39  cases  of  complete  placenta  previa  and 
135  of  the  incomplete  variety. 

Etiology. — Although  little  is  known  concerning  the  exact  etiology  of 
placenta  previa,  the  conditions  which  seem  to  favor  it  are  multiparity  and 
anything  causing  an  enlargement  or  abnormal  shape  of  the  uterus  with 
an  hypertrophy  of  the  endometrium. 


566  HEMORRHAGE 

It  is  much  more  common  in  multigravirhie  than  in  primigravidse. 
In  174  cases  of  placenta  previa  occurring  at  the  Sloane  Hospital  there 
were  148  multigravidse  and  only  20  primigra\ida\ 

The  condition  is  apparently  favored  by  a  subinvolution  of  the  uterus 
resulting  from  numerous  pregnancies  and  especially  from  frequent 
pregnancies. 

It  also  seems  to  be  favored  by  the  presence  of  fibromyomata  in  the 
uterus  enlarging  and  distorting  it.  The  connection  between  these 
conditions  and  placenta  previa  seems  to  be  through  the  resulting  endo- 
metritis preventing  the  normal  embedding  and  vascularization  of  the 
ovum. 

The  view  formerly  accepted  was  that  the  ovum  either  primarily  lodged 
in  the  lower  part  of  the  uterine  cavity  and  developed  there  or  that  in 
a  threatened  abortion  it  loosened  its  primary  attachment  which  was 
higher  up  and  secondarily  formed  an  attachment  and  developed  lower 
do\ATi. 

More  recent  views  are  those  of  Hofmeier  and  Kaltenbach,  and  that 
of  Strassmann.  According  to  Hofmeier  and  Kaltenbach  the  placenta, 
instead  of  developing  wholly  from  the  chorion  and  decidua  basalis 
(serotina),  developed  in  part  from  a  portion  of  the  chorion  in  apposition 
with  the  decidua  capsularis  (reflexa) ;  this  reflexa  placenta  as  pregnancy 
advances  extending  toward  or  over  the  internal  os. 

According  to  Strassmann,  in  placenta  previa,  on  account  of  a  defi- 
cient vascularization  of  the  decidua  basalis  resulting  from  a  previous 
endometritis,  the  placenta  spreads  over  a  larger  area  of  uterine  surface 
to  provide  proper  circulation  and  nutrition,  and  in  doing  so  occasionally 
reaches  or  overlaps  the  uterine  os,  this  extension  being  favored  by  the 
cleavage  of  the  decidua  parietalis  (vera). 

Aiiomalies  of  the  Placenta. — In  placenta  previa  placental  anomalies 
are  common.  Thus  the  placenta  is  often  of  irregular  shape.  It  may 
be  much  more  extensive  than  normal,  as  suggested  by  Strassmann. 
Placentae  succenturiatse  are  not  uncommon.  The  pkcenta  may  be 
composed  of  two  separate  lobes  with  one  on  either  side  of  the  internal 
OS.  Furthermore,  a  part  at  least  of  the  placenta  may  be  abnormally 
adherent. 

Anomalies  of  the  Umbilical  Cord. — The  insertion  of  the  umbilical  cord 
in  placenta  previa  is  often  marginal  or  velamentous,  and  prolapse  of  the 
cord  is  common. 

Anomalies  of  Presentation  and  Position. — The  presence  of  the  placenta 
in  the  lower  uterine  segment  interferes  with  the  normal  descent  of  the 
presenting  part  into  the  pelvis,  thus  favoring  abnormalities  of  presenta- 
tion and  position.  In  the  174  cases  of  placenta  previa  in  20,000  consecu- 
tive deliveries  at  the  Sloane  Hospital  there  were  54  presentations  other 
than  vertex. 

Symptoms. — The  chief  symptom  of  placenta  previa  is  hemorrhage, 
a  flow  usually  of  bright  red  blood  coming  suddenly  and  without  pain, 
unless  the  patient  is  in  labor,  often  when  the  patient  is  perfectly  quiet, 
perhaps  even  asleep.      The  hemorrhage  in  placenta  previa  has  been 


PLACENTA   PREVIA  5S7 

called  "unavoidable,"  to  distinguish  it  from  "accidental"  hemorrhage 
where  the  placenta  is  normally  situated. 

The  first  bleeding  may  occur  at  any  time  from  the  formation  of  the 
placenta  at  the  third  month  until  the  onset  of  labor;  the  most  usual  time, 
however,  is  after  the  sixth  month.  The  first  hemorrhage  may  or  may 
not  be  profuse,  this  depending  as  a  rule  upon  the  nearness  of  approach 
to  the  complete  variety  of  placenta  previa.  The  first  hemorrhage  is 
usually  not  fatal,  but  after  a  little  time  ceases  spontaneously,  only  to 
recur  at  any  moment  and  with  a  severity  which  cannot  be  foretold. 
Exceptions  to  this  general  rule  occasionally  occur:  If  the  placenta  previa 
is  of  the  incomplete,  especially  of  the  lateral  variety,  no  hemorrhage 
may  appear  until  the  labor,  and  perhaps  even  then  the  hemorrhage  will 
not  be  sufficient  to  attract  attention,  as  with  the  rupture  of  the  mem- 
branes the  presenting  part  may  so  compress  the  placenta  against  the 
uterine  wall  as  to  check  any  abnormal  bleeding. 

On  the  other  hand,  there  will  always  remain  impressed  upon  the  author's 
memory  a  case  of  complete  placenta  previa  which  gave  no  hemorrhage 
at  all  during  pregnancy,  but  in  which  at  the  outset  of  labor  there  occurred 
a  hemorrhage  so  profuse  as  to  cause  the  woman  to  faint  and  to  so  exsan- 
guinate her  that  her  life  was  saved  with  great  difficulty.  Thus  far  has 
been  described  what  might  be  called  intermittent  hemorrhages,  but 
occasionally,  instead  of  a  profuse  flow  there  may  be  a  more  or  less  con- 
tinuous dribble  which  gradually  brings  about  a  pronounced  anemia  of 
the  patient,  and  leaves  her  in  a  poor  condition  for  the  grave -hemorrhage 
which  may  occur  unexpectedly  and  suddenly  take  her  life. 

The  question  naturally  arises:  Are  the  time  of  occurrence  of  the  first 
hemorrhage  and  the  amount  of  this  hemorrhage  any  criteria  of  the  variety 
of  the  placenta  previa?  In  general  it  may  be  said  that  the  earlier  in 
pregnancy  the  first  hemorrhage  occurs  and  the  more  profuse  it  is,  the 
more  likely  is  the  condition  to  be  one  of  complete  placenta  previa. 
Attention,  however,  has  already  been  directed  to  the  fact  that  numerous 
exceptions  occur^ 

Cause  of  the  Hemorrhage. — In  a  normal  pregnancy,  especially  in  its 
latter  part,  there  is  a  gradual  thinning  out  and  retraction  of  the  cervix 
and  lower  portion  of  the  uterus  constituting  the  lower  uterine  segment 
(see  page  210),  as  distinguished  from  the  upper  uterine  segment,  which 
is  the  normal  site  of  attachment  of  the  placenta. 

This  retraction  and  thinning  is  brought  about  chiefly  by  the  intermit- 
tent uterine  contractions  which  go  on  through  pregnancy,  as  described  by 
Braxton  Hicks,  and  are  usually  painless,  but  in  some  patients  are  asso- 
ciated with  considerable  discomfort.  In  the  normal  arrangement  the 
placental  attachment  is  not  disturbed  until  after  the  birth  of  the  child, 
when  the  upper  uterine  wall  contracts  away  from  the  placental  surface 
and  by  this  contraction  closes  its  bleeding  sinuses  at  the  same  time. 
In  placenta  previa  the  conditions  are  quite  different.  The  placenta  is 
attached  to  the  lower  uterine  segment  which  must  retract  away  from  it  as 
pregnancy  advances  and  labor  approaches.  The  lower  uterine  segment 
has  little  power  of  muscular  contraction  and  the  separation  may  occur  at 


568  HEMORRHAGE 

a  time  when  even  this  Httle  poAver  is  not  in  action.  \Yhile  in  the  early 
months  the  phicenta  and  tlie  lower  nterine  segment  may  keep  pace  in 
their  growth,  there  soon  comes  a  time  when  the  decidna  will  stand  no 
further  tension  and  the  slightest  increase  may  cause  a  separation  of 
the  placenta  along  the  decidual  layer,  thus  opening  up  the  decidual 
vessels.  This  increase  of  tension  may  arise  from  various  causes:  a  mis- 
step, straining  at  stool,  sexual  intercourse,  a  vaginal  examination,  or  it 
may  come  from  the  extra  congestion  of  the  would-be  menstrual  period, 
or  as  a  result  simply  of  the  normal  intermittent  uterine  contractions 
which  always  accompany  pregnancy.  The  hemorrhage  as  seen  from  the 
above  explanation  is  maternal,  from  the  uterine  sinuses,  as  the  chorionic 
villi  are  usually  not  injured,  and  if  the  fetus  is  killed  by  the  hemorrhage 
it  is  usually  on  account  of  the  fact  that  the  resulting  separation  of  the 
placenta  shuts  ofl'  the  fetal  oxygenation  and  nutrition,  rather  than  on 
account  of  a  fetal  hemorrhage.  The  amount  of  hemorrhage  likely 
to  occur  in  labor  with  a  placenta  previa  cannot  be  predicted  from  the 
amount  of  blood  lost  and  the  frequency  of  the  hemorrhages  in  preg- 
nancy; usually,  however,  the  greater  the  bleeding  in  pregnancy,  the  more 
probability  of  serious  hemorrhage  in  labor. 

In  a  placenta  previa  the  hemorrhage  occurring  during  labor  is  usually 
more  profuse  during  the  interval  between  uterine  contractions,  as  while 
the  uterus  is  contracting  it  forces  the  presenting  part  downward  and  by 
its  pressure  lessens  the  bleeding.  Occasionally,  however,  the  hemor- 
rhage seems  to  be  increased  by  the  contraction,  on  account  of  forcing  out 
of  the  uterus  and  Aagina,  blood  already  lost  in  pre\ious  separation  of  new 
areas  of  placenta. 

After  the  birth  of  a  child  in  a  placenta  previa  the  conditions  differ 
from  those  found  in  a  normal  labor.  There  is  not  the  same  natural 
power  of  complete  separation  of  the  placenta,  and  during  nature's 
attempts  the  hemorrhage  may  be  quite  profuse,  especially  when  con- 
sidered in  connection  with  the  fact  that  the  woman  has  perhaps  already 
lost  considerable  blood. 

For  this  reason,  and  also  for  the  reason  that  the  placenta  is  often 
adherent  in  portions,  it  is  often  wise  to  remove  the  placenta  manually 
and  pack  the  uterus  with  gauze,  as  will  be  discussed  under  Treatment. 

This  abnormal  situation  of  the  placenta  in  the  lower  uterine  segment 
in  front  of  the  child  is  usually  regarded  as  favoring  premature  delivery, 
perhaps  by  premature  rupture  of  the  membranes.  In  the  174  cases 
mentioned  above,  95  were  delivered  prematurely,  although  in  many  the 
premature  labor  was  induced  as  a  part  of  the  treatment. 

Diagnosis. — The  occurrence  of  a  hemorrhage  in  pregnancy  after  the 
period  of  placenta  formation  should  always  suggest  the  possibility  of  a 
placenta  previa,  and  it  should  be  considered  a  probability  unless  it  can 
be  excluded.  It  may  be  an  "accidental"  hemorrhage,  i.  e.,  a  hemorrhage 
from  a  normally  situated  placenta,  but  that  is  usually  associated  with 
urinary  changes  and  other  signs  and  symptoms  of  a  toxemia,  as  will  be 
discussed  later  (see  page  575). 

In  the  absence  of  evidences  of  a  toxemia  it  is  probably  a  placenta  previa. 


PLACENTA   PREVIA  569 

There  are  certain  physical  signs  of  a  placenta  previa  which  should 
assist  in  the  diagnosis.  They  are  usually  all  present  in  the  complete 
variety  and  diminish  in  the  incomplete  with  the  distance  of  the  placenta 
from  the  internal  os  until  in  the  lateral  variety  they  may  be  almost 
absent.    These  physical  signs  are  as  follows: 

On  account  of  the  increased  vascularity  of  the  region  the  cervix  in 
a  placenta  previa  is  usually  softer  and  more  dilatable  than  normal. 

In  the  later  months  it  is  often  partly  dilated.  The  violet  discoloration 
of  the  cervix  and  vaginal  fornix  and  the  vascular  pulsation  of  the  lower 
uterine  segment  are  usually  greater  than  normal. 

The  presenting  part  lies  high  and  between  it  and  the  examining  finger 
can  often  be  detected  the  boggy  mass  of  the  placenta,  making  less  dis- 
tinct the  landmarks  of  the  presenting  part.  If  the  finger  is  introduced 
through  the  cervical  canal  the  placenta  or  its  edge  can  usually  be  felt 
in  all  save  the  lateral  variety.  Objection  has  been  raised  by  some  to  the 
introduction  of  the  finger  lest  it  should  induce  premature  labor,  but  so 
important  is  the  diagnosis  of  placenta  previa  if  present,  and  so  likely  is 
placenta  previa  or  some  other  indication  for  induction  of  labor  to  be 
present  if  a  hemorrhage  occurs  in  pregnancy,  that  the  procedure  is  per- 
fectly justifiable.  Hence  the  rule  which  the  author  gives  his  students: 
that  if  one  is  in  doubt  as  to  the  presence  of  a  placenta  previa,  introduce 
the  finger  into  the  cervical  canal,  under  anesthesia  if  necessary,  and 
palpate  for  the  placenta.  Quite  a  number  of  cases  of  placenta  previa 
of  the  incomplete  variety  escape  diagnosis  until  after  expulsion  of  the 
placenta  and  membranes,  their  careful  examination  showing  then  the 
opening  in  the  membranes  close  to  the  placenta. 

Prognosis. — The  mortality  of  placenta  previa,  both  maternal  and  fetal, 
depends  largely  upon  the  variety  and  the  treatment  undertaken  by  the 
obstetrician. 

The  prognosis  in  the  complete  variety  is  naturally  much  more  grave 
than  in  the  incomplete. 

In  a  combined  series  of  1400  cases  reported  by  Ohlshausen,  Stra^smann, 
Schauta  and  Gussero,  without  regard  to  the  variety  of  the  placenta  previa, 
there  was  a  maternal  mortality  of  8  per  cent.  The  prognosis  for  thq^ 
child  is  always  grave  and  for  the  following  reasons:  In  the  first  place 
it  is  usually  premature,  malpresentation  and  malposition  are  common; 
prolapse  of  the  cord  is  common  and  finally  artificial  delivery  is  usually 
resorted  to  in  the  interest  of  the  mother. 

In  general  the  total  infant  mortality  of  placenta  previa  may  be  given 
as  about  60  per  cent,  or,  if  non-viable  infants  are  excluded,  about  35 
per  cent. 

It  has  already  been  stated  that  the  maternal  mortality  depends  greatly 
upon  the  method  instituted  by  the  obstetrician.  If  the  seriousness  of 
the  situation  is  recognized  and  the  pregnancy  is  terminated  promptly 
the  figures  given  will  fairly  accurately  represent  the  maternal  and  the 
fetal  mortality.  If,  on  the  other  hand,  the  method  pursued  is  to  watch 
and  wait  with  the  hope  that  there  will  be  no  more  hemorrhage,  the  mor- 
tality will  be  much  higher. 


570  HEMORRHAGE 

The  first  question  of  importance  in  any  method  of  treatment  is  the 
maternal  mortahty.  In  a  series  of  5000  consecutive  dehveries  at  the 
Sloane  Hospital,  since  the  use  of  the  elastic  bags  has  been  the  routine 
treatment  of  placenta  previa,  there  have  been  49  cases  of  this  condition, 
14  of  the  complete  and  35  of  the  incomolete  variety. 

In  these  49  cases  there  were  4  deaths  or  8.1  per  cent.,  but  of  these 
4  that  died,  1  died  of  infection  following  a  Cesarean  section,  the  placenta 
previa  being  associated  with  a  flat  pelvis  and  1  died  of  toxemia,  leaving 
only  2  deaths,  or  4  per  cent,  from  uncomplicated  placenta  previa,  and  of 
these  2,  1  lived  only  thirty  minutes  after  reaching  the  hospital,  being 
nearly  moribund  and  with  child  dead  on  admission. 

Of  the  4  that  died,  2  were  those  of  complete  placenta  previa  and  two 
incomplete  (one  partial  and  one  lateral),  the  latter  dying  of  secondary 
conditions,  infection,  and  toxemia.  The  maternal  mortality  then  from 
treatment  of  complete  placenta  previa  by  means  of  the  extra-ovular 
elastic  bag  was  2  in  14,  or  14.2  per  cent. 

As  regards  the  infant  mortality  in  the  49  cases  mentioned  above,  32 
children  were  delivered  alive,  8  died  subsequently,  6  from  prematurity 
and  2  from  other  causes,  and  17  were  stillbirths.  This  gives  a  total 
infant  mortality  of  25  in  49,  or  51  per  cent. 

In  the  49  cases  there  were  10  in  whom  the  pregnancy  had  advanced 
less  than  seven  months,  and  in  1  case  the  child  was  dead  when  the  mother 
entered  the  hospital.  This  left  only  38  cases  in  which  saving  the  life  of 
the  child  could  be  considered  possible  and  of  these  38,  29  children  were 
delivered  alive  and  24  left  the  hospital  alive,  so  that  G3.1  per  cent, 
of  the  children  viable  on  admission  of  the  mother  left  the  hospital  alive. 

Treatment. — When  once  the  diagnosis  of  placenta  previa  is  definitely 
made  there  is  in  private  practice  only  one  safe  rule  of  treatment,  i.  e., 
proceed  to  empty  the  uterus.  The  first  hemorrhage  is  not  usually, 
although  occasionally,  fatal.  The  second  may  be.  The  first  should 
therefore  be  considered  the  red  flag,  or  signal  of  danger  ahead,  and  the 
only  method  should  be  adopted  which  will  free  the  woman  from  danger. 
In  dealing  with  a  case  of  placenta  previa  two  problems  present  them- 
selves before  the  actual  delivery  of  the  child: 

1.  The  control  of  the  hemorrhage. 

2.  The  dilatation  of  the  cervix. 

These  two  problems  are  solved  by  the  use  of  the  Voorhees  modifica- 
tion of  the  Champetier  de  Ribes  bag,  as  is  shown  in  Figs.  363  and  364. 

The  use  of  the  elastic  bag.  is  extra-ovular,  i.  c,  outside  the  membranes, 
which  are  kept  intact.  The  presence  of  the  bag  softens  and  dilates  the 
cervix  and  at  the  same  time  by  pressure  on  the  bleeding  surface  controls 
the  hemorrhage.  With  the  usual  antiseptic  and  aseptic  precautions  one 
of  the  larger  sizes  of  bag  is  introduced  within  the  cervical  canal  and 
distended  with  fluid  (0.5  per  cent,  lysol  solution). 

In  the  ordinary  employment  of  the  Voorhees  bag  for  the  induction 
of  labor  there  is  objection  to  the  largest  bag,  lest  it  displace  the  presenting 
part  and  cause  a  malpresentation  or  a  prolapse  of  the  cord.  In  placenta 
previa  this  objection  does  not  hold,  as  the  presenting  part  usually  lies 


PLACENTA   PREVIA 


571 


high  on  account  of  the  placenta  and  the  dehvery  is  usually  completed 
by  a  version. 

For  this  reason  the  largest  bag  is  employed  which  can  easily  be  intro- 
duced. There  are  many  advantages  in  the  large-sized  bag.  It  is  an 
advantage  to  have  as  few  introductions  as  possible,  both  because  every 
manipulation  favors  more  bleeding,  and  adds  to  the  risk  of  infection, 
and  because  each  manipulation  adds  to  the  discomfort  and  shock  of  the 
patient  who  may  have  been  considerably  reduced  by  hemorrhages. 
Furthermore,  when  once  the  large-sized  bag  has  passed  the  cervix  it  is 
usually  an  easy  matter  to  complete  the  dilatation  manually  and  then  a 
version  can  be  performed,  or  if  it  is  a  breech  presentation  a  foot  can  be 
pulled  down  and  the  child  extracted. 

As  stated  above  the  use  of  the  bag  is  extra-ovular  and  the  membranes 
are  kept  intact  until  the  bag  passes  the  cervix  and  good  dilatation  is 
obtained.    This  method  is  preferred  b}'  the  author  to  the  intra-ovular 


Fig.  363 


Fig.  364 


use  of  the  bag,  where  the  amniotic  sac  is  ruptured  and  the  bag  placed 
within,  chiefly  in  the  interest  of  the  child,  but  with  little,  if  any  detriment 
to  the  interests  of  the  mother. 

If  the  membranes  are  ruptured  and  the  dilating  bag  placed  within  the 
amniotic  sac,  the  version  which  follows  has  to  be  performed  in  a  uterus 
largely  emptied  of  fluid  and  with  greater  danger  to  the  child  and  greater 
danger  of  rupture  of  the  uterus.  Furthermore,  experience  proves  that 
the  presence  of  the  dilating  bag  beneath  the  edge  of  the  placenta  in  an 
incomplete  placenta  previa  (see  Fig.  363)  usually  checks  the  hemorrhage 
without  dissecting  the  placenta  to  any  great  extent  from  the  uterine 
wall,  and  in  the  complete  variety  it  has  seemed  to  cause  less  maternal 
blood  loss  when  used  beneath  the  placenta  (see  Fig.  364)  than  when  the 
placenta  has  been  bored  through  and  the  bag  placed  above  the  placenta 
in  the  amniotic  sac.  It  has  been  argued  that  the  presence  of  the  bag 
beneath  the  placenta  in  a  complete  placenta  previa,  as  shown  in  Fig.  364, 


572  HEMORRHAGE 

would  separate  so  much  of  the  placenta  from  the  uterine  wall  that  the 
fetal  circulation  and  oxygenation  would  be  interfered  with  and  the  child 
be  lost.  Experience  seems  to  show  that  this  interference  with  the  utero- 
placental circulation  is  not  greater  than  in  other  methods  employed  per 
vaginam  and  that  the  fetal  mortality  is  satisfactorily  low. 

Before  the  introduction  of  the  elastic  bag  it  was  the  custom  to  pack 
the  cer\ical  canal  with  gauze  to  soften  and  dilate  it,  then  further  dilate 
the  cervix  manually  until  a  bipolar  version  could  be  done,  when  the  leg 
and  half-breech  would  be  brought  down  to  serve  as  a  tampon  and  dilator. 
This  method  was  a  useful  one,  but  gave  a  higher  fetal  mortality  from  sub- 
jecting the  child  to  longer  pressure  than  the  jiresent  employment  of  the 
elastic  bag  which  secures  a  greater  dilatation  of  the  cervix  before  the 
version. 

Furthermore,  the  cervix  in  placenta  previa  is  apt  to  tear  rather  easily, 
and  an  accouchment  force  without  the  use  of  the  elastic  bag  has  in  not 
a  few  instances  started  a  tear  which  in  the  performance  of  the  ^'ersion 
became  a  rupture  of  the  uterus.  In  cases  of  emergency  and  where  the 
elastic  bags  are  not  at  hand,  packing  the  cervical  canal  with  gauze  and 
performing  a  Braxton  Hicks's  or  bipolar  version  and  pulling  down  one 
foot,  or  if  it  is  a  breech  presenting,  simply  pulling  down  one  foot  will 
often  meet  the  indications;  but  a  long  experience  with  the  bags  has  con- 
vinced the  author  of  their  superiority  in  the  treatment  of  placenta  previa 
where  the  placenta  lies  wholly  or  in  part  over  the  internal  os. 

Is  it  always  necessary  to  do  a  version  in  placenta  previa?     No. 

The  fact  that  some  cases  are  not  diagnosed  until  after  the  labor,  shows 
that  some  cases  gi\'e  little  hemorrhage,  the  descending  head  serving  as 
a  tampon  controlling  bleeding.  This  gives  an  indication  of  treatment 
in  certain  cases  of  vertex  presentation  where  the  finger  detects  a  lateral 
or  marginal  placenta  previa.  In  many  cases  with  little  hemorrhage, 
the  mere  rupture  of  the  membranes,  allowing  the  head  to  come  down 
on  the  placenta,  will  meet  the  indications  and  the  case  may  then  be  left 
to  nature. 

In  some  cases  the  cervix  is  so  well  dilated  when  first  seen  that  no 
preliminary  employment  of  the  elastic  bag  is  needed,  and  after  a  little 
preliminary  dilatation  with  the  fingers  the  patient  may  be  delivered  by 
the  forceps  or  by  version. 

On  the  other  hand,  cases  of  placenta  previa,  especially  primigravidse, 
occasionally  present  themselves,  in  which  the  cervix  is  so  long  and  rigid 
that  the  elastic  bag,  even  one  of  the  smallest  size,  cannot  be  introduced 
without  preliminary  dilatation.  This  can  usually  be  done  by  means  of 
a  glove  stretcher  dilator,  but  must  be  done  with  great  care  on  account 
of  the  risk  of  cervical  laceration,  already  mentioned.  In  these  cases  of 
rigid  cervix  complicating  placenta  pre\ia  there  has  been  a  tendency  of 
late  to  recommend  the  employment  of  abdominal  Cesarean  section. 

The  author  is  free  to  admit  that  exceptionally  a  case  will  present  itself 
in  which  the  placenta  previa  is  central  or  complete,  with  cervix  long, 
with  little  dilatation  and  with  hemorrhage  profuse.  Here  it  is  that 
abdominal  Cesarean  section  may  be  the  procedure  of  choice.    It  should 


PLACENTA   PREVIA  573 

be  borne  in  mind,  however,  that  when  once  a  patient  has  been  deUvered 
by  Cesarean  section,  the  uterine  wall  with  its  cicatrix  is  not  in  as  good 
condition  for  subsequent  labor  on  account  of  possible  yielding  of  the 
uterine  cicatrix  favoring  rupture.  For  this  reason,  and  also  from  the 
fact  that  for  the  ordinary  conditions  found  in  placenta  previa  the  treat- 
ment by  employment  of  the  elastic  bags  has  been  so  satisfactory  in  his 
experience,  the  author  reserves  abdominal  Cesarean  section  in  placenta 
previa  for  exceptional  cases  of  the  complete  variety  with  cervix  undilated 
and  hemorrhage  profuse. 

As  regards  the  employment  of  vaginal  Cesarean  section  or  vaginal 
hysterotomy  in  placenta  previa,  in  spite  of  its  enthusiastic  advocacy  by 
Doderlein,  who  reports  34  consecutive  cases  with  one  maternal  death, 
the  operation  has  few  adherents  in  this  country  or  in  England  or  France. 
In  Germany  a  few  obstetricians  employ  it  in  exceptional  cases,  but  its 
general  use  is  not  to  be  recommended. 

Before  leaving  the  different  methods  of  delivery  in  placenta  previa 
something  should  be  said  regarding  the  technic  of  version  after 
dilatation  of  the  cervix  by  means  of  the  large-sized  elastic  bag.  In 
some  cases  the  placenta  lies  wholly  or  in  part  over  the  internal  os. 
If  the  fingers  can  reach  the  edge  of  the  placenta,  this  should  be  sought 
and  the  fingers  made  to  enter  the  amniotic  sac  around  the  placental  edge. 
If  the  edge  cannot  be  felt,  the  fingers  should  bore  through  the  placenta, 
seize  the  foot  and  extract. 

Even  after  the  child  has  been  delivered,  the  woman  with  placenta 
previa  is  not  out  of  danger.  As  already  stated,  the  placenta  is  often  more 
or  less  adherent  in  places  and  its  site  of  attachment  being  where  there  is 
little  contractile  power  of  the  uterus,  nature  is  often  incapable  of  thor- 
oughly separating  the  placenta  and  until  the  placenta  is  thoroughly 
separated  and  cast  oft'  there  is  likelihood  of  hemorrhage. 

Furthermore,  even  after  the  uterus  is  entirely  emptied  the  dilated 
sinuses  in  the  lower  uterine  segment  often  bleed  more  than  when  these 
sinuses  at  the  placental  site  are  situated  in  the  upper  uterine  segment. 
For  these  reasons  it  is  well  as  a  routine  procedure  after  emptying  the 
uterus  in  a  placenta  previa  to  pack  the  uterine  cavity  with  gauze  to 
prevent  further  loss  of  blood.  The  gauze  for  intra-uterine  packing  is 
better  impregnated  with  bismuth  than  plain,  as  plain  gauze  does  not 
remain  sweet  in  the  uterine  cavity  for  the  twenty-four  hours  usually 
desired,  and  a  woman  who  has  been  the  subject  of  a  placenta  previa, 
who  has  lost  considerable  blood,  and  whose  sinuses  in  the  lower  uterine 
segment  contain  large  thrombi  very  easily  becomes  infected.  In  fact 
it  is  a  very  common  thing  for  a  patient  with  placenta  previa  to  run  a 
little  temperature  after  delivery,  even  if  the  delivery  has  been  conducted 
with  the  strictest  precautions. 

At  the  beginning  of  the  discussion  of  the  treatment  of  placenta  previa 
the  statement  was  made  that  when  once  the  diagnosis  was  definitely 
made  there  was  in  private  practice  only  onp  safe  rule  of  treatment,  i.  e., 
proceed  to  empty  the  uterus.  It  might  be  further  added  that  in  the  treat- 
ment of  placenta  previa  the  mother's  life  should  always  receive  first 


574  HEMORRHAGE 

consideration  and  the  child's  second.  The  child  being  usually  premature 
and  the  fetal  mortality  always  relatively  high. 

In  a  hospital  service  with  patients  surrounded  by  nurses  and  with 
several  doctors  in  the  building  and  instruments  and  dressings  near  at 
hand  this  rule  of  ])roceeding  to  empty  the  uterus  in  the  incomplete 
variety  of  placenta  previa  may  be  modified  somewhat  if  the  child  is  near 
the  period  of  viability  and  a  few  weeks  more  of  pregnancy  would  be 
likely  to  secure  a  living  child.  Even  in  a  hospital  service  this  should 
only  be  done  in  the  lateral  or  marginal  varieties  of  placenta  previa, 
and  where  the  ^■ertex  presents,  so  that  the  rupture  of  the  membranes 
would  in  all  probability  allow  the  head  to  come  down  and  sufficiently 
tampon  the  bleeding  surface.  If,  under  these  conditions  the  patient  is 
kept  constantly  in  bed  and  under  close  observation,  the  little  risk  may 
sometimes  be  justifiable.  The  question  now  arises.  Are  there  conditions 
which  would  ever  justify  such  temporizing  in  private  practice?  The 
author  has  occasionally  made  use  of  the  following  plan  which  is  applicable 
in  a  large  city  like  New  York,  but  not  in  the  country. 

In  a  case  of  lateral  or  marginal  placenta  previa  where  the  placenta 
at  the  most  only  reaches  the  internal  os,  with  a  night  and  day  nurse  in 
attendance  and  with  sterile  gauze  packing,  speculum  and  dressing  forceps 
at  the  bedside,  and  a  telephone  connection  in  the  house,  he  has  arranged 
with  several  of  his  medical  friends,  thoroughly  informed  as  to  the  con- 
dition of  the  patient,  to  answer  a  call  to  her  house  if  they  should  receive 
a  summons.  In  this  way  the  patient  was  reasonably  certain  of  obtaining 
medical  aid  at  short  notice,  even  if  her  attending  obstetrician  could  not 
be  obtained.  This  method  has  succeeded  in  sa^'ing  the  lives  of  some 
children  which  otherwise  it  would  have  seemed  necessarv  to  sacrifice. 


HEMORRHAGE   WITH    A   NORMALLY    SITUATED    PLACENTA. 

It  has  been  shown  that  with  placenta  previa,  an  abnormally  situated 
placenta,  hemorrhage  may  occur  either  antepartum  or  intrapartum.  It 
will  now  be  seen  that  hemorrhage  may  occur  either  antepartum  or  intra- 
partum with  a  normally  situated  placenta. 

Hemorrhage  with  a  normally  situated  placenta  may  be  one  of  two 
varieties: 

1.  There  may  occur  one  or  more  hemorrhages  into  the  substance  of 
the  placenta,  the  condition  being  spoken  t)f  as  "placental  apoplexy." 

2.  Hemorrhage  may  occur  between  the  placenta  and  the  uterine  wall 
from  premature  separation  of  a  normally  situated  placenta,  this  being 
called  "accidental  hemorrhage." 

ACCIDENTAL  HEMORRHAGE. 

The  premature  separation  of  a  normally  situated  placenta  may  occur 
either  during  pregnancy  or  during  labor,  it  being  very  much  more 
frequent  in  the  former  than  in  the  latter. 

Some  idea  of  the  frequency  of  accidental  hemorrhage  may  be  gained 


ACCIDENTAL  HEMORRHAGE 


575 


from  the  fact  that  in  the  20,000  consecutive  dehveries  at  the  Sloane 
Hospital,  212  cases,  or  a  frequency  of  1  in  94,  a  little  more  than  1  per 
cent.,  were  considered  cases  of  this  condition.  Cases  simply  showing 
a  few  blood-clots  or  with  a  history  of  slight  bleedings  in  pregnancy  were 
not  included. 

Varieties. — Premature  separation  of  a  normally  situated  placenta  may 
be  complete,  as  indicated  by  the  term  (see  Fig.  365),  or  incomplete  in  which 
only  a  portion  is  separated;  this  separation  occurring  at  its  centre;  its 
periphery,  or  anywhere  between  (see  Figs.  366  and  367). 

The  hemorrhage  resulting  from  this  separation  may  be  external  or 
concealed.    The  former  being  about  three  times  as  frequent  as  the  latter. 

In  the  series  of  212  cases  just  quoted  there  were  159  cases  with  external 
hemorrhage  and  53  with  the  hemorrhage  concealed. 


Fig.  365 


Fig.  366 


Fig.  367 


Fig.  365. — Complete  premature  separation  of  normalh'  situated  placenta. 

Fig.  366. — Incomplete  separation  of  normal^'  situated  placenta.     External  hemorrhage. 

Fig.  367. — Incomplete  separation  of  normally  situated  placenta.     Concealed  hemorrhage. 


The  most  usual  occurrence  is  that  the  margin  of  the  placenta  becomes 
separated  and  the  hemorrhage  works  its  way  down  between  the  mem- 
branes and  the  uterine  wall  (see  Fig.  366)  until  it  escapes  externally.  On 
the  other  hand,  it  may  be  concealed  in  several  ways: 

1.  The  centre  only  of  the  placenta  may  be  detached. 

2.  The  hemorrhage  may  dissect  upward  rather  than  downward. 

3.  The  hemorrhage  may  rarely  break  through  into  the  amniotic  sac. 

4.  The  cervica  canal  may  be  plugged  b}'  blood-clots,  the  membranes 
or  the  presenting  part,  so  that  no  blood  escapes  externally. 

Etiology. — The  predominating  factor  in  the  etiology  of  premature 
separation  of  a  normally  situated  placenta  is  a  toxemia  with  a  diseased 
decidua  favoring  the  occurrence  of  the  hemorrhage  which  is  the  imme- 
diate cause  of  the  separation.  The  same  tendency  to  the  occurrence  of 
hemorrhage  in  the  toxemia  of  pregnancy  which  is  seen  in  the  liver,  the 
kidneys,  the  retina,  the  mucosa  of  the  alimentary  canal  and  the  skin,  is 
shown  here  in  the  decidua  of  the  uterus.  The  same  condition  of  premature 
separation  of  the  placenta  in  the  early  months  of  its  formation  is  seen 


576  HEMORRHAGE 

in  the  repeated  miscarriages  of  the  third  and  fourth  months  in  women  who 
suffer  from  a  toxemia  every  time  they  become  jjregnant. 

So  frequent  is  the  association  of  a  toxemia  with  "accidental  hemor- 
rhage" that,  as  already  suggested  during  the  discussion  of  placenta  previa, 
if  a  pregnant  jiatient  has  a  hemorrhage  and  at  the  same  time  shows 
the  urinary  changes  or  other  evidences  of  a  well-marked  toxemia,  the 
probable  diagnosis  is  an  "accidental  hemorrhage"  rather  than  a  placenta 
previa. 

Certain  constitutional  diseases  also  cause  premature  separation  of 
a  normally  situated  placenta  by  producing  a  diseased  decidua  with  the 
tendency  to  hemorrhage.  Among  such  diseases  may  be  mentioned 
syphilis,  smallpox,  scarlet  fever,  etc.  Any  overdistention  of  the  uterus, 
as  by  hydramnios  or  multiple  pregnancy,  seems  to  predispose  to  a 
looser  attachment  of  the  placenta  than  normal,  and  hence  to  favor  its 
premature  separation. 

Multiparity  favors  this  occurrence,  as  is  shown  by  the  fact  that  in  the 
series  of  212  cases  already  mentioned  there  were  139  multigravidse  and 
only  73  primigravidse. 

A  short  cord,  either  actually  short  or  shortened  by  being  wound  about 
some  portion  of  the  fetus,  may  by  traction  on  the  placenta,  as  the  child 
descends,  cause  a  premature  separation  of  the  placenta  with  death  of  the 
fetus. 

A  sufficient  number  of  cases  of  "accidental  hemorrhage"  following  a 
traumatism,  as  a  severe  blow  or  violent  muscular  efl'ort,  have  been 
reported  to  show  that  these  cannot  be  disregarded  as  possible  causes  of 
premature  separation  of  the  placenta,  and  finally  the  instrument  of  the 
abortionist  introduced  between  the  fetal  membranes  and  the  uterine 
wall  may  mechanically  separate  the  placenta  and  accomplish  his  dire 
purpose. 

Symptoms  and  Signs. — The  symptoms  of  a  premature  separation  of  a 
normally  situated  placenta  in  the  early  months  of  pregnancy  are  usually 
simply  those  of  a  threatened  abortion,  i.  e.,  hemorrhage  with  or  without 
pain. 

The  lesion  is  practically  identical  with  that  of  an  abortion  as  it  is  the 
separation  of  the  chorion  from  the  uterine  wall.  The  discharge  of  blood, 
usually  external,  may  be  either  bright  or  dark,  scanty  or  profuse. 

It  is  usually  rather  scanty  in  amount  at  first  and  is  often  not  very 
bright.  Later  in  pregnancy,  especially  near  term  or  during  labor,  the 
symptoms  are  more  or  less  pronounced,  depending  upon  the  degree  of 
separation  of  the  placenta. 

A  complete  premature  separation  of  a  normally  situated  placenta  near 
term  presents  to  the  obstetrician  one  of  the  greatest  problems  with 
which  he  has  to  deal  and  sometimes  furnishes  him  an  experience  which 
ever  after  remains  indelibly  impressed  upon  his  mind. 

The  picture  may  be  something  as  follows:  A  patient  with  albuminuria 
and  other  evidences  of  a  toxemia  begins  to  have  pain  in  the  abdomen 
with  or  without  a  discharge  of  blood  from  the  vagina.  The  pain  is 
not  the  intermittent  type  of  labor  pains,  but  is  more  or  less  constant. 


ACCIDENTAL  HEMORRHAGE  577 

The  patient  feels  faint  and  shows  anemia.  Her  pulse  becomes  poor, 
and  she  is  evidently  in  shock.  The  uterine  wall  feels  tense,  perhaps  bulg- 
ing on  one  side  over  the  placental  site  and  the  uterus  as  a  whole  has 
increased  greatly  in  size.  The  fetal  parts  are  less  easy  to  make  out  than 
at  the  previous  examination,  and  the  fetal  heart  beat  can  probably  not 
be  detected.  If  this  premature  separation  occurs  during  labor  the  regular 
labor  pains  cease.  The  continuous  stretching  pain  of  the  uterus  distend- 
ing with  blood  appears  in  their  place  and  the  woman  rather  rapidly  pre- 
sents the  picture  of  shock  and  internal  hemorrhage  with  pallor,  a  feeble 
pulse,  etc. 

The  usual  picture  of  accidental  hemorrhage  is  a  combination  of  toxemia 
with  that  of  shock  and  internal  hemorrhage.  There  is  often  a  little  exter- 
nal bleeding,  but  our  worst  cases  are  usually  those  of  complete  separation 
of  the  placenta  with  concealed  hemorrhage. 

Diagnosis. — If  external  bleeding  accompanies  premature  separation  of 
a  normally  situated  placenta  near  term  the  condition  must  be  diagnosed 
first  from  placenta  previa.  A  few  of  the  differential  features  are  here 
presented. 

Premature  Separation  of  Placenta vs. Placenta  Previa. 

Toxemia  usually  present.  Toxemia  usually  not  present. 

Pain  usually  continuous.  Without  pain  unless  in  labor. 

No  placenta  felt  through  cervix.  Perhaps  placenta  felt. 

Uterine  wall  in  continuous  tension.  Uterine  wall  relaxes. 

Uterus  rapidly  increases  in  size.  Uterus  does  not  increase  in  size. 

Evidences  of  shock  and  hemorrhage.  Only  evidences  of  hemorrhage. 

Fetal  death  more  common.  Fetal  death  less  common. 
Perhaps  bulging  of  uterus  at  placental  site.  No  such  bulging  of  uterus. 

The  symptoms  may  resemble  those  of  rupture  of  the  uterus.    In  both 
there  are  hemorrhage,  shock,  and  perhaps  marked  pain. 
Some  of  the  differential  features  are  as  follows : 

Premature  Separation  of  Placenta vs. Rupture  of  Uterus. 

Occurs  in  pi'egnancy  or  early  in  labor.  Usually  occurs  late  in  protracted  and  diflS- 

cult  labor. 

Toxemia  usually  present.  Toxemia  usually  not  present. 

Membranes  usually  unruptured.  Membranes  usually  ruptured. 

Upper  uterine  segment  distended  and  tense.  Upper  uterine  segment  smaller  and  con- 
tracted. 

Presenting  part  does  not  recede.  Presenting  part  recedes. 

If  the  "accidental  hemorrhage"  is  concealed  the  diagnosis  should 
always  be  suggested  by  the  large,  tense  uterus,  with  constant  pain  and 
evidences  of  shock  and  internal  hemorrhage,  especially  in  a  patient 
suffering  with  the  toxemia  of  pregnancy. 

Prognosis. — Accidental  hemorrhage  in  the  latter  months  of  pregnancy 
or  in  labor  is  often  one  of  the  most  serious  complications  of  obstetrics  and 
always  has  a  high  maternal  and  fetal  mortality.  The  maternal  mortality, 
as  reported  by  different  observers,  is  usually  given  as  from  30  to  50  per 
cent.,  and  the  fetal  mortality  as  from  85  to  95  per  cent. 
37 


578  HEMORRHAGE 

In  the  series  of  212  cases  at  the  Sloane  Hospital  there  were  12  maternal 
deaths,  giving  a  total  maternal  mortality  of  5.7  per  cent. 

In  these  212  cases  the  hemorrhage  was  of  the  external  variety  in  159, 
with  8  deaths,  giving  a  mortality  of  5.03  per  cent., ^  and  of  the  concealed 
variety  in  53  with  4  deaths,  giving  a  mortality  of  7.5  per  cent. 

In  the  212  cases  there  were  122  fetal  deaths,  giving  a  total  fetal  mor- 
tality of  57.5  per  cent.;  of  these  122  fetal  deaths,  22  were  abortions  i.  e., 
non-viable.  Hence,  in  the  series  of  212  cases  there  were  190  viable 
fetuses  and  of  these  100  were  lost,  a  mortality  of  52.6  per  cent. 

The  reasons  for  the  high  maternal  and  fetal  mortality  in  accidental 
hemorrhage  are  obvious.  The  patient  at  the  time  of  the  accident  is 
usually  in  poor  condition  on  account  of  the  toxemia.  She  is  then  reduced 
to  a  condition  of  shock,  and  in  this  shock,  in  order  to  save  her  from  fatal 
hemorrhage,  she  is  subjected  to  an  artificial  delivery. 

The  high  fetal  mortality  is  a  natural  result  of  the  toxemia  of  the  mother, 
the  premature  separation  of  the  placenta,  the  artificial  delivery  and  the 
prematurity  of  the  fetus.  In  the  above  series  of  212  cases,  120.  or  more 
than  half,  were  premature. 

Treatment. — The  treatment  varies  with  the  period  of  pregnancy  and 
the  severity  of  the  condition.  In  the  earlier  months  of  pregnancy  soon 
after  the  formation  of  the  placenta,  and  while  the  uterus  is  still  small, 
a  slight  accidental  hemorrhage  may  occur  with  a  separation  of  the 
placenta  so  slight  as  not  to  interfere  with  the  life  and  development  of 
the  fetus.  Such  a  condition  under  rest  and  symptomatic  treatment  will 
often  be  recovered  from,  and  at  the  delivery  of  the  placenta  the  former 
occurrence  of  the  accidental  hemorrhage  will  be  evidenced  simply  by  the 
white  placental  infarct. 

IMoreover,  even  a  more  extensive  separation  of  the  placenta,  when  the 
uterus  is  small,  as  in  the  first  half  of  pregnancy,  usually  subjects  the 
mother  to  relatively  little  risk  from  hemorrhage  or  shock.  In  well-marked 
cases  near  term,  however,  where  the  s^Tiiptoms  of  shock  and  internal 
hemorrhage  are  distinct,  no  temporizing  methods  will  answer,  the  woman 
is  in  grave  danger  and  only  prompt  and  intelligent  treatment  will  save 
her  and  even  that  may  fail. 

The  indication  is  to  empty  her  uterus  without  adding  more  than  is 
absolutely  necessary  to  her  shock.  The  one  barrier  to  this  accomplish- 
ment is  the  condition  of  the  cervix  and  it  is  often  this  condition  of  the 
cervix  which  marks  the  difference  between  success  and  failure  in  the 
treatment  of  cases  of  complete  premature  separation  of  a  normally 
situated  placenta. 

If  the  cervix  is  dilated  or  dilatable  the  uterus  can  be  easily  and  promptly 
emptied  and  packed  with  gauze  and  the  woman  rescued  from  her  danger. 

On  the  other  hand,  if  the  cervix  is  long  and  rigid,  with  the  woman 
toxic  and  suftering  from  severe  shock  and  hemorrhage,  the  obstetrician 
is  face  to  face  with  a  problem  which  he  would  gladly  escape.  Realizing 
that  the  object  desired  as  the  first  step  toward  emptying  the  uterus  is 
the  dilatation  of  the  cervix,  the  best  method  is  usually  to  introduce  an 
elastic  bag  into  the  cervical  canal  at  once.  The  patient's  shock  and  general 


ACCIDENTAL  HEMORRHAGE  579 

condition  can  then  be  treated  by  stimulation,  infusion,  or  direct  trans- 
fusion, as  conditions  indicate,  while  the  cervix  is  softening  and  dilating 
under  the  influence  of  the  elastic  bag. 

After  sufficient  softening  and  dilatation  the  cervix  can  be  dilated 
manually  and  the  fetus  delivered  by  version  or  forceps  as  seem  best 
under  the  circumstances. 

In  the  cases  of  complete  separation  of  the  placenta  the  fetal  life  is  so 
often  destroyed  before  delivery  that  it  is  considered  perfectly  justifiable 
in  these  grave  cases  to  disregard  the  life  of  the  fetus,  and  if  the  mother 
can  be  more  easily  and  quickly  delivered  by  a  craniotomy,  to  perform  it 
in  her  interest. 

In  the  cases  of  long,  rigid  cervix  which  do  not  dilate  readily  under  the 
use  of  the  elastic  bag,  the  vaginal  Cesarean  section  has  a  limited  but 
valuable  field  of  usefulness.  The  abdominal  Cesarean  section  also  in 
certain  rare  cases  may  be  the  operation  of  choice.  It  should  be  remem- 
bered, however,  that  these  patients  are  usually  in  shock  and  in  poor 
condition  for  surgical  operation  and  the  procedure  which  adds  least  to 
their  shock  will  usually  give  the  best  results. 

Even  after  the  uterus  is  emptied,  the  patient  is  not  out  of  danger,  as 
the  author  has  learned  to  his  sorrow.  These  uteri  which  have  been 
markedly  dilated,  and  in  women  who  have  lost  considerable  blood,  tend 
to  relax  after  delivery  and  add  a  postpartum  to  an  accidental  hemorrhage. 

As  a  prophylactic  procedure,  it  is  always  well  after  the  uterus  is  emptied, 
to  pack  its  cavity  with  gauze  and  have  the  fundus  carefully  guarded  for 
at  least  an  hour. 

Ergot  should  be  used  as  a  routine  procedure.  The  extract  of  pituitary 
gland  will  probably  prove  useful  in  such  cases. 

In  addition  to  these  drugs  the  ordinary  methods  for  overcoming  shock 
and  toxemia,  if  present,  are  indicated. 

It  has  been  shown  that  an  antepartum  hemorrhage  may  occur  either 
with  an  abnormally  situated  placenta  (placenta  previa)  or  with  a  nor- 
mally situated  placenta  (accidental  hemorrhage). 

It  may  also  occur  with  an  abnormally  situated  placenta  and  fetus,  i.  e., 
with  an  ectopic  gestation,  due  to  the  separation  of  the  uterine  decidua 
(see  page  531). 

Intrapartum  hemorrhage  has  been  shown  to  occur  either  with  placenta 
previa  or  with  a  separation  of  a  normally  situated  placenta  (accidental 
hemorrhage).  It  may  also  arise  from  laceration  of  any  portion  of  the 
parturient  canal  from  fundus  to  vulva.  The  only  lacerations  likely  to 
cause  serious  hemorrhage  during  labor  are: 

1 .  Lacerations  of  the  cervix. 

2.  Rupture  of  the  uterus. 

Lacerations  of  the  Cervix. — It  is  not  often  that  a  laceration  of  the 
cervix  will  cause  serious  hemorrhage  during  labor,  but  the  author  was 
called  to  one  case  in  consultation  in  which  the  attending  obstetrician 
in  dilating  manually  a  long,  rigid  cervix  during  a  tedious  labor,  met  with 
a  hemorrhage  from  laceration  of  the  circular  artery  which  nearly  exsan- 
guinated the  woman.    In  such  an  emergency  it  is  sometimes  necessary 


580  HEMORRHAGE 

to  put  a  suture  of  catgut  around  the  bleeding  vessel,  although  in  most 
instances  it  is  sufficient  to  pack  the  cervical  canal  and  vagina  with  gauze 
until  the  presenting  part  comes  down  and  by  its  pressure  controls  the 
bleeding.  The  laceration  most  likely  to  prove  serious  during  labor  is  a 
rupture  of  the  uterus. 

Rupture  of  the  Uterus. — A  solution  of  continuity  in  the  uterine  wall 
other  than  a  laceration  of  the  cervix,  may  occur  during  pregnancy,  labor, 
or  the  ])uerperium.  Its  occurrence,  however,  during  pregnancy  and  the 
puerperium  is  so  exceptional  that  the  expression — rupture  of  the  uterus 
- — is  usually  interpreted  as  a  complication  of  labor. 

Etiology." — Rupture  of  the  uterus  is  predisposed  to  by  anything  weaken- 
ing the  uterine  wall,  as  a  fatty  degeneration  of  its  muscle  fibres;  a  separa- 
tion of  its  muscle  fibres,  as  by  the  presence  of  a  fibromyoma;  an  inroading 
of  its  wall  as  by  an  hydatidiform  mole;  an  overdistention  of  its  wall;  a 
cicatrix  in  its  wall,  as  from  a  previous  laceration  or  operation;  a  necrosis 
of  its  wall,  as  from  prolonged  pressure,  or  a  septic  infection  which  markedly 
softens  its  wall.  ^Moreover,  uterine  rupture  is  predisposed  to  by  multi- 
parity  and  by  abnormal  presentations.  In  30  cases  of  rupture  of  the 
uterus  occurring  at  the  Sloane  Hospital  23  were  in  multigravidje  and  7 
in  primigra\idje,  and  among  the  30  there  were  11  abnormal  presentations. 

Rupture  of  the  uterus  during  pregnancy  usually  occurs  as  a  result  of 
an  abnormal  pregnancy,  as  an  interstitial  pregnancy  or  an  hydatidiform 
mole  which  gradually  inroads  the  uterine  wall  until  it  perforates  it. 

lvui)ture  of  the  uterus  during  the  puerperium  usually  occurs  as  a  result 
of  necrosis  following  prolonged  pressure,  a  septic  uterus,  or  of  a  currettage 
in  a  septic  uterus. 

When  a  portion  of  the  lower  uterine  segment  is  unduly  compressed 
between  the  presenting  part  and  a  sharp  promontory  of  the  sacrum  or 
an  exostosis  of  the  pelvis  the  part  thus  compressed  may  slough  out, 
leaving  a  small  opening  through  the  uterus.  The  same  result  may 
occur  with  a  normal  pelvis  if  a  fetal  head,  too  large  to  pass  the  canal,  is 
allowed  to  press  too  long  against  the  lower  uterine  segment. 

A  more  common  cause  of  postpartiun  rupture  of  the  uterus  is  perhaps 
a  currettage  of  a  septic  uterus  in  which  the  operator,  not  perceiving  that 
he  has  passed  the  boundary  of  the  decidua,  continues  the  use  of  the 
curette  until  it  has  gone  entirely  through  the  uterine  wall. 

While  a  weakening  of  the  uterine  wall  by  fatty  degeneration,  cicatrices 
and  tiunors  undoubtedly  serves  as  a  predisposing  factor,  the  one  cause 
of  rupture  of  the  uterus  which  stands  out  above  everything  else  is  over- 
distention :  tension  of  the  lower  uterine  segment,  produced  by  the  uterus 
working  too  long  against  an  obstacle  to  the  birth  of  the  child.  We  are 
indebted  to  Bandl  for  our  knowledge  of  the  behavior  of  the  uterus  in 
prolonged  labor. 

The  upper  uterine  segment,  as  described  on  page  211,  is  the  active  por- 
tion and  contracts  and  retracts  while  the  lower  portion  dilates  to  allow 
the  i)assage  of  the  child.  The  lower  edge  of  this  upper  uterine  segment, 
called  the  contraction  ring  or  ring  of  Bandl,  at  the  beginning  of  labor  lies 
at  about  the  level  of  the  pelvic  brim  and  nearly  corresponds  on  the 


ACCIDENTAL  HEMORRHAGE  581 

uterus  with  the  attachment  of  the  peritoneum  to  it.  If  an  obstacle  to 
the  dehvery  of  the  child  exists,  whether  the  dystocia  is  due  to  an  obstruc- 
tion in  the  bony  pelvis  or  soft  parts  of  the  canal,  or  whether  it  is  due 
to  an  abnormal  size  or  presentation  of  the  child,  this  upper,  active  uterine 
segment  retracts  and  thickens  until  the  contraction  ring,  ^^^hich  can  be 
distinctly  felt,  approaches  nearer  and  nearer  to  the  level  of  the  umbilicus. 
The  lower  uterine  segment  on  the  other  hand,  especially  if  the  cervix  is 
caught  beneath  the  presenting  part,  becomes  thinner  and  thinner  until 
it  can  stand  no  further  tension  without  yielding. 

Uteri,  the  seat  of  an  old  cicatrix  in  the  upper  uterine  segment,  as  from 
a  previous  Cesarean  section,  will  often  show^  this  cicatrix  as  the  part 
of  least  resistance  and  the  yielding  of  the  wall  will  occur  here,  but  in 
uteri  without  cicatrices  it  is  in  the  lower  uterine  segment  which  is  the 
yielding,  tliinning  portion. 

With  a  portion  of  the  uterus  stretched  to  its  limit,  its  rupture  may 
occur  in  one  of  two  ways: 

1.  It  may  occur  spontaneously. 

2.  It  may  occur  through  intervention. 

There  is  no  doubt  that  a  uterus  will  occasionally  rupture  spontaneously 
if  left  too  long  working  against  an  obstacle  to  delivery;  the  thinned  out 
uterine  wall  finally  yielding  under  the  influence  of  uterine  contractions 
alone. 

JNIuch  more  commonly,  however,  rupture  occurs  as  the  result  of  inter- 
vention by  the  obstetrician,  and  the  one  fact  in  this  connection  above 
all  others  which  the  student  of  obstetrics  should  have  impressed  upon 
his  mind,  is  that  a  tonic  uterus  with  upper  uterine  segment  contracted 
and  retracted,  with  the  ring  of  Bandl  near  the  umbilicus  and  the  lower 
uterine  segment  thinned  out,  is  just  the  uterus  to  rupture  if  it  is 
subjected  to  any  more  tension  within  it,  as  by  a  version  or  any 
intra-uterine  manipulation. 

]Moreover,  a  rupture  of  the  uterus  often  occurs  as  an  extension  of  one 
or  more  of  the  lacerations  of  the  cervix  produced  in  the  course  of  an 
accouchement  force.  This  is  especially  true  in  the  case  of  a  placenta 
previa,  where  the  lower  uterine  segment  is  rendered  more  friable  by  the 
dilated  sinuses  and  where  the  obstetrician  in  order  to  save  the  mother 
from  further  loss  of  blood  is  anxious  to  complete  the  delivery  as  soon  as 
he  reasonably  can.  It  has  also  occurred  a  number  of  times  in  the  course 
of  an  accouchement  force  in  cases  of  eclampsia  with  long,  rigid  cervix, 
where  the  cervix  w^as  torn  rather  than  stretched,  and  where  the  cervical 
tear  made  by  the  hand  became  a  uterine  tear  when  the  version  and 
extraction  were  performed. 

Frequency. — Fortunately  rupture  of  the  uterus  is  a  rare  accident  and 
it  will  become  still  more  rare  when  the  dangers  of  version  in  a  tonic  uterus 
and  a  very  rapid  accouchement  force,  with  a  long,  rigid  cervix  are  more 
generally  understood. 

The  frequency  of  rupture  of  the  uterus  is  variously  stated  by  different 
observers,  but  is  usually  given  as  about  1  in  1000  cases.  Statistics  in 
private  practice  are  often  misleading,  as  autopsies  after  confinement  in 


582  HEMORRHAGE 

private  practice  are  few  and  the  death  resulting  from  uterine  rupture 
has  not  infrequently  been  assigned  to  shock,  postpartum  hemorrhage,  or 
sepsis. 

It  is  in  maternit}'  hospitals  where  accurate  records  are  kept  that  reli- 
able statistics  are  obtained,  yet  in  these  unusual  accidents  a  very  large 
service  is  necessary  for  valuable  conclusions  as  to  their  frequency. 

In  a  series  of  20,000  consecutive  deliveries  at  the  Sloane  Hospital 
there  were  30  cases  of  rupture  of  the  uterus  treated;  15  of  these  occurred 
outside  of  the  hospital  and  were  admitted  with  this  complication. 

If  all  cases  at  the  hospital  were  considered  it  w^ould  make  a  frequency 
of  1  in  666f  cases.  If  only  those  occurring  in  the  hospital  were  counted 
the  frequency  would  be  1  in  1333^  cases. 

Varieties. — The  most  practical  classification  of  cases  of  rupture  of  the 
uterus  is  to  consider  them  as  examples  either  of  complete  or  incomplete 
rupture. 

A  complete  rupture  of  the  uterus  is  one  in  which  the  rent  extends  through 
the  uterine  wall  and  opens  the  peritoneal  cavity. 

An  incomplete  rupture  is  one  in  which  the  rent  does  not  open  the  peri- 
toneal cavity.  In  the  series  of  30  cases  treated  at  the  Sloane  Hospital, 
16  were  of  the  complete  and  14  of  the  incomplete  variety. 

Pathology. — The  tear  in  the  uterus  may  be  either  longitudinal  or 
transverse,  or  a  combination  of  the  two.  It  may  involve  the  anterior, 
the  posterior  or  either  of  the  lateral  walls.  As  the  occiput  more  often 
lies  to  the  mother's  left,  it  is  the  lower  uterine  segment  on  the  left  side 
which  is  usually  subjected  to  the  greatest  amount  of  tension  and  hence 
the  rupture  is  most  often  found  on  the  left  side.  A  rupture  starting  with 
a  laceration  of  the  cervix  is  apt  to  be  more  or  less  longitudinal,  while  a 
spontaneous  rupture  in  a  uterus  not  subjected  to  a  previous  Cesarean 
section  is  apt  to  be  transverse  and  to  involve  either  the  anterior  or  pos- 
terior uterine  wall. 

Spontaneous  rupture  in  a  case  previously  subjected  to  a  Cesarean 
section  naturally  takes  the  direction  of  the  uterine  cicatrix. 

In  one  case  brought  to  the  author's  service  the  uterus  was  nearly  sepa- 
rated from  the  vaginal  portion  of  the  cervix  by  a  transverse  rupture. 

The  edges  of  the  uterus  are  usually  ragged  and  irregular.  If  the  rupture 
is  incomplete  and  occurs  as  an  extension  of  a  laceration  of  the  vaginal 
portion  of  the  cervix  it  often  goes  into  the  broad  ligament  and  the  hemor- 
rhage opens  out  its  folds  and  strips  the  peritoneum  from  the  anterior  or 
posterior  surface  of  the  uterus,  especially  the  former.  In  this  subperi- 
toneal space  may  be  found  more  or  less  of  the  placenta  and  fetus  together 
with  blood-clots.  On  the  other  hand,  neither  the  fetus  nor  the  placenta 
may  have  passed  through  ,the  rent  and  the  condition  be  only  detected 
by  a  postpartum  examination. 

The  hemorrhage  taking  place  into  this  subperitoneal  space  may  cease 
spontaneously,  unless  the  uterine  artery  has  been  torn,  and  form  a  large 
pelvic  hematoma  which  may  be  absorbed,  or  by  a  recurrence  of  the 
hemorrhage  may  break  through  into  the  peritoneal  cavity,  or  the  pelvic 
hematoma  may  become  infected,  subjecting  the  patient  to  the  dangers 


ACCIDENTAL  HEMORRHAGE  583 

of  a  pelvic  abscess.  If  the  rupture  of  the  uterus  lacerates  the  uterine 
artery,  even  the  incomplete  variety  of  the  accident  may  prove  fatal  from 
hemorrhage.  The  complete  variety  of  rupture  is  apt  to  prove  fatal  from 
septic  peritonitis,  even  if  the  women  survive  the  initial  hemorrhage. 

Symptoms. — A  spontaneous  rupture  of  the  uterus  during  pregnancy 
usually  presents  the  symptoms  of  a  ruptured  ectopic  gestation  (see  page 
542).  and  will  not  be  further  discussed  here.  The  symptoms  of  rupture 
of  the  uterus  occurring  during  labor  usually  follow  those  of  a  protracted 
labor  with  membranes  ruptured  and  with  little  advance.  At  the  time 
of  the  rupture  the  woman  usually  has  a  sharp  abdominal  pain,  the  regular 
labor  pains  cease  and  she  presents  the  picture  of  shock  and  internal 
hemorrhage;  especially  is  the  condition  of  shock  usually  pronounced, 
with  pallor,  rapid,  feeble  pulse,  etc. 

This  is  the  rule,  and  yet  some  patients  will  be  very  deceptive  in  their 
clinical  picture.  There  may  be  very  little  external  hemorrhage  and  the 
shock  may  for  a  time  be  slight,  so  that  the  obstetrician  is  surprised  to 
find  on  examination  that  the  woman  has  a  rupture.  This  condition  of 
relative  well-being  is  more  apt  to  be  associated  with  the  incomplete 
rather  than  the  complete  variety  of  uterine  rupture. 

Whenever  a  woman  immediately  following  delivery  presents  the  clini- 
cal picture  of  pronounced  shock  without  hemorrhage  enough  to  account 
for  it,  the  possibility  of  rupture  of  the  uterus  should  always  be  thought 
of.  The  hemorrhage  may  be  slight  and  may  be  largely  internal  rather 
than  external.  The  physical  signs  vary  with  the  individual  case  and  the 
conditions  existing.  If  the  fetus  and  placenta  have  largely  escaped  into 
the  abdominal  cavity,  abdominal  palpation  will  often  detect  the  con- 
tracted empty  uterine  body  riding  upon  an  irregular  mass,  which  occupies 
the  lower  portion  of  the  abdominal  cavity.  The  abdomen  itself  is 
usually  distended.  Vaginal  examination  will  detect  under  these  circum- 
stances a  recession  of  the  presenting  part  and  the  fingers  introduced 
into  the  cervical  canal  will  pass  into  the  rent. 

If  the  uterine  rupture  is  only  diagnosed  after  the  delivery  the  obstet- 
rician may  be  surprised  to  find  that  his  fingers  pass  through  a  rent  into 
the  peritoneal  cavity  and  that  he  distinctly  feels  intestine,  or  that  in  the 
incomplete  variety  of  rupture,  his  fingers  pass  up  along  the  uterus  without 
feeling  intestine  and  that  with  his  other  hand  on  the  abdomen  he  can 
easily  approximate  them  with  only  the  abdominal  wall  and  peritoneum 
between  them. 

Prognosis. — The  mortality  of  rupture  of  the  uterus,  both  maternal 
and  fetal,  is  high.  The  mother  is  exposed  to  the  immediate  risk  of  severe 
hemorrhage  and  shock  and  to  the  later  risk  of  infection.  The  child  is 
exposed  to  the  risk  of  the  protracted  labor  which  usually  precedes  the 
rupture  and  then  to  the  risk  of  asphj'xia  from  separation  of  the  placenta 
from  the  uterine  wall.  The  maternal  and  fetal  mortality  usually  each 
approximates  85  per  cent. 

In  the  30  cases  of  rupture  of  the  uterus  occurring  in  20,000  consec- 
utive deliveries  at  the  Sloane  Hospital,  the  maternal  mortality  was  26, 
or  86f  per  cent. 


584  HEMORRHAGE 

In  this  same  series  the  fetal  inortahty  was  24,  or  SO  per  cent. 

The  maternal  mortality  is  less  in  the  incomplete  than  in  the  com]>lete 
variety  of  rupture.  In  this  series  of  'M)  cases,  10  were  of  the  complete 
variety  and  14  of  the  incomplete.  In  the  16  complete  ruptures  the 
mortality  was  15,  or  93.7  per  cent.,  while  in  the  14  incomplete  ruptures 
the  mortality  was  11,  or  78.5  per  cent. 

The  26  maternal  deaths  of  this  series  at  the  Sloane  Hospital  were 
assigned  as  follows:  Hemorrhage  and  shock,  15;  sepsis,  9;  eclampsia 
and  not  due  to  rupture,  2.  Many  of  these  cases  were  nearly  moribund 
or  profoundly  septic  on  admission. 

If  the  woman  dies  as  a  result  of  the  hemorrhage  and  shock  the  death 
usually  occurs  within  twenty-four  hours,  while  death  from  infection  may 
be  postponed  several  days. 

Women  who  have  recovered  from  a  rupture  of  the  uterus  seem  rather 
prone  to  a  recurrence  of  the  accident  in  a  subsequent  labor  as  reported 
by  Peham  and  IMikhine. 

Treatment. — The  most  important  and  most  hopeful  treatment  of  rup- 
ture of  the  uterus  is  prophylaxis.  It  is  through  the  general  recognition 
of  the  danger  of  rupture,  if  a  version  is  attempted  in  a  tonic  uterus,  that 
this  accident  will  be  avoided.  Furthermore,  if  the  danger  of  a  rapid 
mechanical  dilatation  of  a  long,  rigid  cervix  without  previous  prepara- 
tion by  softening  is  recognized,  there  will  be  fewer  cases  of  extension  of 
cervical  tears  into  the  lower  uterine  segment. 

Prophylactic  treatment  implies  a  careful  study  of  each  individual 
obstetric  case  during  pregnancy  and  labor,  so  that  the  relative  size  of  the 
child  and  birth  canal  together  with  the  presentation  will  be  known  before 
labor  begins.  Moreover,  during  the  labor  any  delay  in  its  progress  and 
any  marked  thinning  of  the  lower  uterine  segment  should  be  looked 
upon  with  suspicion  and  the  obstetrician  be  in  readiness  to  aid  nature 
whenever  it  is  needed,  and  before  the  integrity  of  the  uterine  wall  is 
endangered. 

If  rupture  of  the  uterus  has  actually  occurred  the  treatment  indicated 
depends  upon: 

1.  The  variety  of  the  rupture — complete  or  incomplete. 

2.  The  amount  of  shock. 

In  the  first  place  the  fact  should  be  established  by  careful  examination 
whether  the  rupture  has  opened  the  peritoneal  cavity  or  not. 

If  the  rupture  has  been  proved  to  be  incomplete  the  uterus  should  be 
emptied  if  not  already  empty;  its  cavity  and  the  cavity  created  by  the 
rent  should  be  firmly  packed  with  sterile  (better  bismuth  or  weak  iodo- 
form) gauze  and  the  woman  then  treated  symptomatically.  The  use  of 
ergot,  saline  infusion  and  cardiac  stimulation  are  the  usual  indications. 

If,  on  the  other  hand,  examination  discloses  a  complete  rupture,  the 
first  problem  may  be  that  of  dealing  with  the  fetus  and  placenta  if  still 
undelivered.  If  they  are  still  in  the  uterus  or  uterus  and  vagina,  as  a 
rule  they  should  be  delivered  -per  vias  naturales,  reducing  the  size  of  the 
fetus  by  craniotomy  or  embryotomy  if  necessary  to  facilitate  delivery. 

The  next  indication  is  usually  to  open  the  abdomen,  remove  the  blood- 


POSTPARTUM  HEMORRHAGE  585 

clots,  the  fetus  and  the  placenta,  if  they  have  escaped  from  the  uterus 
mto  the  abdominal  cavity,  and  then  deal  ^^•ith  the  rent  according  to  the 
conditions  found.  If  the  rent  is  small  and  the  edges  not  very  ragged 
the  best  procedure  is  to  suture  the  rent,  cleanse  the  abdominal  cavity 
and  close  it.  If,  on  the  other  hand,  the  tear  in  the  uterus  is  extensive 
and  the  edges  irregular  and  ragged,  the  best  plan  is  to  complete  the 
operation  by  a  hysterectomy. 

The  question  now  arises,  Is  the  amount  of  shock  ever  a  contra-indica- 
tion  to  the  abdominal  operation  even  in  a  complete  rupture?  The  best 
answer  to  this  question  is  an  affirmative  one.  There  are  cases  in  which 
the  woman  is  in  extreme  shock  in  which  the  hemorrhage  is  not  very 
active  and  in  which  the  probability  is  great  that  if  subjected  to  an 
abdominal  operation  at  once  she  would  be  lost  upon  the  table.  Under 
such  circumstances  as  these  the  best  treatment  is  to  pack  the  uterus  and 
rent  firmly  with  gauze  to  prevent  any  further  hemorrhage  and  then 
endeavor  to  overcome  the  shock  of  the  woman.  Not  infrequently  at 
the  end  of  twelve  to  twenty-four  hours  the  woman  has  rallied  suffi- 
ciently to  enable  her  to  endure  an  abdominal  operation  and  then  the 
intra-abdominal  problems  can  be  dealt  with  as  above. 

As  to  the  treatment  of  a  perforation  of  the  uterine  wall  caused  by  a 
pressure  necrosis,  whether  the  opening  be  anterior  into  the  bladder  or 
posterior  into  the  peritoneum  or  rectum,  it  may  be  said  that  better 
results  are  usually  obtained  by  leaving  the  patient  alone  with  the  hope 
that  nature  will  clean  and  close  the  fistula,  rather  than  by  operation. 

If  the  perforation  of  the  uterus  has  been  caused  by  a  curette,  it  is 
usually  the  wisest  plan  to  open  the  abdomen  and  deal  with  the  uterine 
rent  according  to  the  conditions  found,  either  suturing  the  rent  if  the 
uterus  is  not  infected  or  performing  hysterectomy  if  the  rent  is  large  and 
ragged  and  the  organ  septic.  A  number  of  cases  of  perforation  of  the 
non-pregnant  uterus  with  sound  or  curette  have  been  reported  in  which 
the  abdomen  was  not  opened  and  yet  the  woman  recovered.  In  the 
pregnant  or  recently  pregnant  uterus,  however,  the  conditions  for  which 
a  curette  would  be  likely  to  be  used  are  so  often  septic  and  the  risk  of 
carrying  septic  material  into  the  peritoneal  cavity  by  the  perforation  is 
so  great,  that  abdominal  section  is  usually  the  best  method  of  dealing 
with  perforations  of  the  pregnant  uterus. 

If  a  loop  of  intestine  has  prolapsed  into  a  ruptured  or  perforated  uterus 
the  indication  is  to  open  the  abdomen  and,  aside  from  either  suturing 
the  rent  in  the  uterus  or  performing  hysterectomy,  to  deal  with  the 
loop  of  intestine   according  to   its   vitality,   cleansing   and   leaving,   or 

resecting  it. 

* 

POSTPARTUM   HEMORRHAGE. 

This  term  is  usually  applied  to  a  hemorrhage  occurring  within  twenty- 
four  hours  from  the  birth  of  the  child  and  is  usually  called  primary  if  it 
occurs  T\dthin  the  first  hour  before  the  abdominal  binder  is  applied  and 
secondary  if  it  occurs  later.     For  convenience  in  description,  in  histories 


586  HEMORRHAGE 

of  patients,  it  is  the  custom  to  divide  hemorrhage  into  three  different 
degrees  (arbitrary  of  course)  according  to  the  amount  lost. 

Thus  hemorrhage  of  the  first  degree,  sixteen  to  twenty-four  ounces. 

Hemorrhage  of  the  second  degree,  twenty-four  to  thirty-two  ounces. 

Hemorrhage  of  the  third  degree,  thirty-two  ounces  or  over. 

Frequency. — An  idea  of  the  frequency  of  occurrence  of  postpartum 
hemorrhage  will  be  gained  from  the  records  of  20,000  consecutive  deliv- 
eries at  the  Sloane  Hospital.  In  this  series  not  only  was  the  occurrence 
of  postpartum  hemorrhage  recorded,  but  the  different  degrees  of  hemor- 
rhage were  noted.  Of  course  the  personal  equation  of  the  observer  enters 
largely  into  the  record  of  blood  lost  in  each  case,  and  yet  the  series  is 
large  enough  to  furnish  a  reliable  average. 

In  the  20,000  deliveries  there  were  2118  cases  in  which  a  blood  loss  of 
sixteen  ounces  or  more  was  recorded.  This  gave  a  frequency  of  10.5  per  cent. 

This  frequency  varied  greatly  in  the  different  thousands,  from  21.6 
per  cent,  in  the  fourth  thousand  to  1.9  per  cent,  in  the  nineteenth 
thousand.  The  average  frequency  of  occurrence  of  the  different  degrees 
of  hemorrhage  was  first  degree,  6.4  per  cent.;  second  degree,  2.6  per  cent.; 
third  degree,  1.5  per  cent,  of  cases. 

Etiology. — For  a  proper  understanding  of  the  etiology  of  postpartum 
hemorrhage,  nature's  provision  for  the  control  of  bleeding  after  the 
separation  and  expulsion  of  the  placenta  must  first  be  considered. 

1.  The  dilated  uterine  sinuses  are  surrounded  by  muscle  fibers  and 
bundles,  some  longitudinal  and  some  circular,  the  contraction  and  retrac- 
tion of  which  have  a  tendency  to  close  the  lumina  of  the  vessels. 

2.  The  increased  coagulability  of  the  blood  in  the  latter  part  of  preg- 
nancy and  in  labor  with  the  leukocytosis  and  the  diapedesis  of  the 
leukocytes  into  the  connective  tissue  surrounding  the  uterine  sinuses, 
favors  thrombosis  in  these  vessels. 

3.  The  slowing  of  the  current  of  blood  through  these  sinuses  still 
further  favors  the  process  of  coagulation  and  thrombosis.  All  three  are 
normally  in  action  in  the  control  of  hemorrhage  after  a  normal  labor. 

Of  these  three,  the  contraction  and  retraction  of  the  musculature  of 
the  uterine  wall  are  the  most  important.  In  fact  it  is  upon  the  normal 
contraction  and  retraction  of  the  uterus  after  labor  that  the  safety  of  the 
woman  depends.  In  general,  postpartum  hemorrhage  may  be  looked 
upon  as  due  to  one  or  other  of  two  causes: 

1.  A  failure  of  the  uterus  to  normally  contract  and  retract. 

2.  A  laceration  of  the  parturient  canal  opening  a  vessel  or  vessels  of 
importance. 

Failure  of  the  uterus  to  normally  contract  and  retract,  or  relaxation  of 
the  uterus  may  be  due  to  several  causes,  both  predisposing  and  exciting. 

Predis'posing  Causes. — In  general,  multiparity  favors  relaxation  of  the 
uterus,  postpartum  hemorrhage  occurring  about  twice  as  often  in  mul- 
tipara?  as  in  primiparte.  An  overtired  muscle,  as  after  a  protracted  labor; 
an  overstretched  muscle,  as  in  multiple  pregnancy  or  hydramnios;  a 
poorly  developed  muscle;  a  muscle  weakened  by  disease  or  bad  hygiene; 
a  too  rapidly  emptied  muscle;  a  muscle  with  defective  innervation:   All 


POSTPARTUM  HEMORRHAGE  ^  587 

these  conditions  may  be  considered  as  predisposing  to  a  relaxation  of  the 
uterine  muscle. 

Another  cause  which  deserves  emphasis  is  prolonged  anesthesia  which 
often  leaves  the  uterus  wdth  poor  contractile  power.  Furthermore,  cer- 
tain general  conditions  of  the  woman  such  as  pulmonary,  cardiac,  or 
hepatic  disease,  by  interfering  with  the  normal  balance  of  circulation, 
tend  to  bring  about  the  same  condition.  Certain  conditions  of  the 
blood,  as  anemia  or  toxemia,  are  often  associated  with  uterine  relaxation. 
The  presence  of  a  tumor,  as  a  fibromyoma  in  the  uterine  wall,  and  the 
presence  of  anything  in  the  uterine  cavity,  whether  it  be  a  tumor,  a  por- 
tion of  the  placenta  or  a  blood-clot,  interferes  with  normal  contraction 
of  the  uterus  and  so  predisposes  to  hemorrhage.  Postpartum  hemor- 
rhage is  common  after  placenta  previa,  as  the  dilated  uterine  sinuses  are 
then  situated  in  the  lower  segment,  which  has  little  contractile  power. 

The  interference  with  a  normal  uterine  contraction  may  be  outside  the 
uterus  and  may  be  due  to  a  distended  bladder  or  rectum.  It  may  be 
due  to  adhesions  between  the  uterus  and  the  neighboring  viscera  or 
between  the  uterus  and  the  abdominal  wall.  It  may  be  due  to  conditions 
of  the  nervous  system,  as  mental  excitement,  grief,  anger,  etc. 

Foremost  among  the  exciting  causes  of  postpartimi  hemorrhage  stands 
a  mismanagement  of  the  second  and  third  stages  of  labor.  An  improper 
employment  of  Crede's  expression  of  the  placenta,  either  too  early,  too 
rapid  or  too  forcible  favors  improper  uterine  contraction  and  hemor- 
rhage. 

Diagnosis. — The  first  question  in  postpartum  hemorrhage  is  the 
diagnosis  of  its  existence  and  its  source.  The  hemorrhage,  of  course, 
usually  appears  externally,  and  it  is  then  easy  for  any  observer  to  tell 
that  the  woman  is  bleeding.  On  the  other  hand,  the  uterus  may  relax 
and  concealed  blood  accumulate  within  it  until  the  woman  is  nearly 
exsanguinated.  In  other  words,  the  woman  may  nearly  bleed  herself 
to  death  into  her  o^mi  uterus,  the  hemorrhage  being  concealed  and  the 
patient  simply  presentijig  the  constitutional  symptoms  of  hemorrhage. 

This  concealed  pastpartum  hemorrhage  with  an  unruptured  uterus  will 
not  occur  if  the  fundus  is  carefully  guarded  in  the  third  stage,  and  dur- 
ing the  hour  following.  The  criterion  of  this  concealed  hemorrhage  is 
the  feel  of  the  fundus.  If  the  fundus  is  firm  and  well  contracted  and  no 
bleeding  appears  externally  the  woman  is  not  suffering  from  postpartum 
hemorrhage. 

On  the  other  hand,  it  may  be  difficult  at  first  to  locate  the  fundus, 
which  may  be  like  a  lax  bag,  but  soon  a  little  friction  identifies  it  and  a 
little  compression  expels  large  masses  of  blood-clot  and  fluid  blood  and 
the  fundus  then  resumes  its  normal  consistency  and  normal  postpartum 
size. 

If  the  woman  is  bleeding  externally  the  question  is,  What  is  the  source 
of  the  hemorrhage?  The  diagnosis  is  made  by  the  condition  of  the  fundus. 
If  the  fundus  is  not  firm  and  compression  of  it  expels  clots  and  fluid 
blood,  the  source  of  the  hemorrhage  is  the  relaxed  uterine  body.  But 
if  the  fundus  is  firm  and  well  contracted  and  the  bleeding  still  continues. 


588  HEMORRHAGE 

the  source  oi  the  hemorrhage  is  a  laceration  of  tJie  lower  parturient  canal, 
the  cervix,  va<j;ina,  or  vuh'a. 

Physical  Signs  and  Symptoms.  TJie  first  e\i(icnce  of  postpartum 
hemorrhage  is  usually  a  freer  discharge  of  blood  than  normal  from  the 
vulva  outlet  detected  while  cleansing  the  i)erineum  prior  to  the  applica- 
tion of  the  vulva  pads,  or  it  may  be  the  too-rapid  soaking  of  the  vulva 
pads  with  blood.  The  sign  which  deserves  especial  emphasis  because 
the  one  sought  at  once  on  seeing  or  being  told  that  the  woman  is 
bleeding  is  a  relaxed  fundus.  The  condition  has  been  described  when 
discussing  the  diagnosis. 

The  constitutional  symptoms  of  severe  postpartum  hemorrhage  if 
once  seen  can  never  be  forgotten.  The  pallor;  rapid  and  feeble  pulse; 
the  restlessness;  air  hunger;  the  patient  wishing  the  windows  open  and 
asking  to  be  fanned;  the  pinched  face;  dry  lips  and  tongue,  and  thin, 
peaked  nose. 

This  is  the  picture  of  hemorrhage.  It  is  astonishing  how  much  blood 
some  women  can  lose  without  showing  marked  symptoms  of  its  loss  and 
how  rapidly  they  will  recover  if  the  hemorrhage  is  checked  and  yet  after 
repeated  hemorrhages  a  small  additional  blood  loss  in  some  women  will 
l)rove  fatal. 

Treatment. — The  most  important  feature  in  the  treatment  of  post- 
partum hemorrhage  is  prophylaxis.  This  means  a  proper  hygiene  during 
pregnancy  with  plenty  of  fresh  air,  with  suitable  food  and  exercise.  It 
also  means  intelligent  conduct  of  the  different  stages  of  labor,  especially 
the  second  and  third.  In  the  second  stage  the  woman  should  not  be 
allowed  to  go  too  long  unaided  lest  the  uterus  become  overtired  and 
relax  later.  She  should  not  be  given  too  much  anesthetic,  especially  if 
chloroform  is  used. 

The  proper  management  of  the  third  or  placental  stage  is  perhaps 
the  most  important  of  all.  Sufficient  time  under  ordinary  circumstances 
should  be  given  for  the  uterus  to  contract  upon  the  placenta  or  away  from 
it  and  so  complete  the  separation  and  expulsion  of  both  placenta  and 
membranes. 

The  rule  followed  at  the  Sloane  Hospital  is  to  allow  twenty  minutes  for 
this  process.  Occasionally  a  portion  of  the  placenta  becomes  separated 
in  advance  of  the  rest,  perhaps  because  the  remainder  is  abnormally 
adherent  or  because  there  is  a  divided  placenta;  at  any  rate,  the  surface 
from  which  the  separation  occurred  may  bleed  quite  profusely  as  regular 
uterine  contraction  is  prevented  by  the  portion  of  the  placenta  still 
attached.  Under  these  circumstances  the  indication  is  usually  to  empty 
the  uterus  without  waiting  for  the  twenty  minutes  to  elapse. 

In  the  expression  of  the  placenta  by  Crede's  method,  the  most  impor- 
tant precaution  is  to  attempt  the  expression  only  during  a  contraction 
of  the  uterus.  Strong,  downward  compression  of  a  relaxed  uterine  bofly 
tends  to  cause  an  inversion  of  the  uterus  thus  favoring  the  occurrence  of 
a  hemorrhage  rather  than  preventing  it. 

To  avoid  hemorrhage  from  retained  secundines  the  placenta  and  mem- 
branes should  be  carefully  examined  after  expulsion,  arid  if  any  large 


POSTPARTUM  HEMORRHAGE  589 

portion  is  missing  it  should  be  removed  manually  with  the  gloved  hand. 
Attention  has  already  been  called  to  the  fact  that  to  ensure  the  uterus 
maintaining  its  normal  postpartum  contraction,  its  fundus  should  be 
carefully  guarded  for  an  hour  after  the  delivery  of  the  child.  In  the 
active  treatment  of  postpartum  hemorrhage  the  first  step  is  to  seize 
the  fundus  through  the  abdominal  wall  and  if  it  is  not  found  well  con- 
tracted, to  manipulate  it  until  it  contracts  firmly  and  the  uterus  expels 
its  contents,  as  it  is  the  form  of  postpartum  hemorrhage  with  relaxed 
uterus,  which  one  is  most  frequently  called  upon  to  treat.  This  will 
be  considered  first,  leaving  the  hemorrhage  from  laceration  of  the  lower 
parturient  canal  with  contracted  fundus  until  later. 

Having  stimulated  the  uterus  to  contract  and  having  made  sure 
that  it  is  empty,  even  by  the  introduction  of  the  gloved  hand  if  neces- 
sary, the  next  problem  is  to  maintain  this  contraction.  While  the  hand 
is  in  the  uterine  cavity  the  uterus  usually  contracts  well,  and  especially 
if  the  other  hand  upon  the  abdomen  is  compressing  the  fundus,  according 
to  the  method  of  Gooch,  the  bleeding  usually  ceases.  This  same  result 
can  usually  be  brought  about  by  Breisky's  method  of  uterine  compression, 
by  which  the  uterus  is  compressed  between  the  fingers  of  the  two  hands, 
one  making  upward  pressure  in  the  anterior  fornix  and  the  other  on  the 
abdominal  w^all  making  downward  pressure  upon  the  uterine  fundus. 
These,  however,  are  only  temporary  procedures. 

For  maintaining  uterine  contractions  we  have  three  general  methods, 
any  or  all  of  which  may  be  wisely  made  use  of.    They  are: 

1 .  The  use  of  drugs. 

2.  The  douche. 

3.  Intra-uterine  gauze  tamponade. 

Drugs. — As  a  rule  some  preparation  of  ergot,  as  the  fluidextract  Sij, 
has  been  given  by  the  mouth  immediately  following  the  expulsion  of  the 
placenta.  At  any  time  after  a  half -hour  one-half  this  dose  may  be 
repeated,  or  better,  a  corresponding  hypodermic  dose  of  aseptic  ergot 
may  be  given.  The  extract  of  the  pituitary  gland  often  proves  most 
useful  under  these  circumstances. 

The  Douche. — If  a  sterile  douche  bag,  tube  and  nozzle  are  at  hand, 
as  should  always  be  the  case,  a  hot  intra-uterine  douche  of  a  temperature 
116°  to  120°  F.  may  be  given  wath  advantage.  As  a  rule  a  sterile  normal 
salt  solution  is  the  best,  although  the  douche  may  be  made  more  astrin- 
gent by  using  2  to  4  per  cent,  acetic  acid  solution,  or  hot  iodin  solution 
may  be  used,  adding  iodin  to  sterile  water  until  it  assmnes  a  wine  color. 
If,  with  the  employment  of  the  hot  douche,  prepared  in  one  of  the  ways 
just  mentioned,  the  uterus  does  not  maintain  its  contraction  and  the 
hemorrhage  cease,  the  best  procedure  is  an  intra-uterine  tamponade. 

Gauze  Tamponade. — Although  plain  sterile  gauze  may  be  used  for  an 
intra-uterine  tamponade,  it  does  not  remain  sweet  long  in  the  parturient 
canal,  where  the  blood  and  mucus  with  which  it  becomes  soaked  soon 
impart  to  it  a  disagreeable  odor.  For  this  reason  at  the  Sloane  Hospital 
it  is  the  custom  for  all  intra-uterine  and  vaginal  packing  to  use  a  bismuth 
gauze  (bismuth  subcarbonate,  1  ounce;  glycerin,  1  ounce;  water,  1  pint); 


590  HEMORRHAGE 

the  gauze  is  soaked  in  this,  then  drietl  and  steriHzed),  or  a  o  per  cent, 
iodoform  gauze.  The  bismuth  gauze  usually  remains  sweet  for  twenty- 
four  hours  and  does  not  carry  with  it  the  characteristic  disagreeable 
odor  of  iodoform. 

In  the  use  of  any  gauze,  as  an  intra-uterine  tamponade,  great  care 
must  be  taken  that  the  gauze  does  not  become  infected  during  its  intro- 
duction. 

The  best  plan  is  always  to  carry  in  one's  obstetric  outfit  glass  tubes 
containing  strip  gauze  pre})ared  for  intra-uterine  packing  in  case  of  need. 
When  introducing  it  into  the  uterus,  the  tube  of  gauze  is  held  by  the 
nurse  above  the  pubes,  the  perineum  is  retracted  with  a  speculum,  the 
cervix  is  pulled  do\\Ti  with  a  vulsellum  and  as  the  labia  are  separated 
the  gauze  is  passed  with  a  long  forceps,  as  for  instance,  a  loop-ended 
sponge  holder,  into  the  cavity  of  the  uterus,  clear  to  the  fundus.  It  is 
important  that  the  gauze  reach  the  fundus  so  as  to  leave  no  space  in  the 
upper  part  of  the  uterine  cavity,  where  the  blood  may  accumulate  and 
balloon  the  uterus.  For  this  reason  it  is  well  to  have  a  hand  on  the  fundus 
as  the  gauze  is  carried  carefully  upward  until  it  meets  with  resistance. 
That  part  of  the  gauze  is  then  released  and  a  portion  seized  lower  down ; 
this  is  passed  upward  and  so  on  until  the  cavity  of  the  uterus  and  then 
the  vaginal  canal  are  filled. 

Conditions  sometimes  arise,  as  in  extreme  emergencies,  where  the 
speculum  and  vulsellum  are  not  to  be  had.  Under  these  circumstances 
an  intra-uterine  tamponade  can  be  done  with  any  long  forceps  like  the 
sponge  holder.  The  perineum  can  be  depressed  with  the  back  of  the 
gloved  left  hand  introduced  into  the  vagina  and  along  the  palm  of  this 
hand,  which  also  separates  the  \Tilva,  the  gauze  can  be  passed  into  the 
uterus  as  before. 

In  other  emergencies  the  sterile  gauze  may  either  be  lacking  or  be  in 
insufficient  quantity  and  yet  the  woman  is  bleeding  profusely.  Any 
freshly  laundered  material  like  a  sheet  may  be  torn  up  and  used  for  the 
tamponade.  It  may  be  argued  that  the  sheet  is  not  sterile  and  there  is 
risk  of  infection.  That  is  all  true,  but  the  woman  is  bleeding  profusely 
and  the  danger  of  death  from  hemorrhage  is  greater  than  that  from 
infection  from  freshly  laundered  sheets,  which  probably  do  not  contain 
pathogenic  organisms  of  marked  virulence.  The  lesser  risk  must  be 
chosen.  The  amount  of  gauze  needed  to  control  some  cases  of  post- 
partmu  hemorrhage  is  considerable.  In  one  case,  whose  life  the  author 
probably  saved  through  the  intra-uterine  tamponade,  he  used  twenty 
yards  of  strip  packing  a,nd  two  towels  before  the  hemorrhage  ceased. 
The  intra-uterine  tamponade  is  usually  removed  at  the  end  of  twenty-four 
hours.  Having  checked  the  hemorrhage  the  problem  then  presented  is 
the  treatment  of  the  general  condition  of  the  patient. 

The  i»dications  depend  largely  upon  the  condition  of  the  pulse.  If 
this  is  fair,  keeping  the  patient  quiet,  surrounded  with  hot  blankets,  wdth 
head  low,  perhaps  with  the  foot  of  the  bed  elevated  and  the  restlessness 
relieved  by  a  small  dose  of  morphin  will  meet  the  indications.  In 
extreme  cases,  where  the  pulse  is  very  feeble  or  impalpable  at  the  wrist, 
other  measures  must  be  resorted  to.    The  amount  of  blood  loss  should 


POSTPARTUM  HEMORRHAGE  591 

in  part  at  least  be  replaced  by  an  intravenous  saline  infusion  or  by  sub- 
cutaneous h^^podermoclysis. 

The  limbs  of  the  patient  should  be  bandaged  to  maintain  as  much  of 
the  blood  of  the  body  as  possible  in  the  trunk.  Cardiac  stimulants  should 
be  administered  and  of  these  strychnin  is  one  of  the  best.  The  uterine 
fundus  should  be  carefully  guarded  to  prevent  further  hemorrhage  and 
some  recommend  the  compression  of  the  abdominal  aorta.  The  question 
of  cardiac  stimulation  in  uterine  hemorrhage  is  one  demanding  careful 
judgment.  The  uterus  may  not  bleed  if  the  vascular  tension  is  low, 
while  if  the  tension  is  greatly  increased  by  cardiac  stimulation  the  thrombi 
may  become  loosened  and  hemorrhage  recur.  The  knowledge  of  experi- 
ence is  a  most  valuable  asset  in  these  decisions  and  can  only  be  gained 
by  considering  the  dangers  of  too  low  blood-pressure  on  the  one  hand  and 
too  high  blood-pressure  on  the  other  and  then  endeavoring  in  each  case 
to  take  the  middle  ground. 

The  women  in  these  cases  of  postpartum  hemorrhage  are  thirsty  from 
loss  of  blood,  and  allowing  them  to  drink  freely  of  water  as  soon  as  the 
stomach  will  retain  it  and  the  frequent  administration  of  a  saline  enema 
will,  as  a  rule,  not  only  relieve  the  thirst,  but  improve  the  quality  of  the 
pulse. 

Laceration  of  the  Lower  Parturient  Canal. — Thus  far  we  have  been 
considering  postpartum  hemorrhage  with  relaxed  uterine  body.  In  some 
cases  examination  of  the  fundus  shows  it  well  contracted,  yet  bright 
red  blood  is  trickling  freely  over  the  perineum.  This  means  that  there 
is  some  laceration  of  the  lower  parturient  canal.  It  may  be  at  the  vesti- 
bule or  in  the  vagina,  but  is  probably  in  the  cervix. 

The  source  of  this  bleeding  should  be  sought  and  if  it  is  at  all  pronounced 
it  should  be  checked  by  suture.  If  it  comes  from  the  cervix,  a  vulsella 
in  its  anterior  lip,  or  in  the  absence  of  a  vulsella,  a  stitch  placed  in  the 
anterior  lip,  will  draw  the  cervix  into  view,  especially  if  the  perineum 
is  retracted  with  a  speculum  (see  Fig.  368).  The  laceration  can  then  be 
repaired.  Care  should  be  taken  on  the  one  hand  to  place  the  first  stitch 
high  enough  to  include  the  upper  angle  of  the  tear  and  on  the  other  hand 
care  should  be  taken  that  the  last  stitch  does  not  close  the  cervical  canal 
so  tightly  as  to  interfere  with  drainage  and  so  favor  infection.  These 
lacerations  are  usually  best  sutured  with  chromicized  catgut,  which 
holds  the  tissues  in  apposition  until  union  is  complete,  but  does  not  have 
to  be  removed. 

Inversion  of  the  Uterus. — One  of  the  complications  of  delivery  occa- 
sionally associated  with  postpartum  hemorrhage,  although  fortunately 
a  rare  occurrence,  is  an  inversion  of  the  uterus.  A  condition  in  which,  in 
its  complete  form,  the  uterus  is  turned  wrong  side  out  and  upside  down. 
The  inversion,  however,  instead  of  being  complete  (as  sho-^^i  in  Plate 
IX,  dra^Ti  from  a  photograph  of  a  case  seen  in  consultation  by  the 
author),  may  be  incomplete  and  consist  simph'  of  a  downward  cupping 
of  the  fundus.  The  frequency  is  usually  stated  as  about  once  in  200,000 
cases,  although  most  consulting  obstetricians  of  large  experience  have 
seen  several  cases.     It  seems  to  be  much  more  common  in  primiparse 


592 


HEMORRHAGE 


than  in  multipara\  It  usually  occurs  in  the  third  stage  of  labor,  but  has 
been  reported  as  occurring  as  late  as  the  second  week.  These  late  cases 
may  have  been  o\erlooked  earlier.  It  may  recur  after  replacement,  as 
reported  by  Fisher,  on  the  third  day. 

Etiology. — The  conditions  necessary  for  the  occurrence  of  an  inversion 
of  the  uterus  after  labor  are  a  relaxation  of  the  fundus  and  a  dilatation 
of  the  cer\"ix.  ^^  ith  these  conditions  present  it  may  occur  in  one  of  three 
ways. 

1 .  It  may  be  pushed  down  from  above. 

2.  It  may  be  pulled  down  from  below. 

3.  It  may  fall  down  spontaneously. 


Fig.  36S. — Showing  a  recent  cervical  tear.      (Bunim.) 


The  most  usual  cause  of  an  inversion  of  the  uterus  is  the  improj)er 
application  of  Crede's  method  of  expression  of  the  placenta.  This  should 
only  be  practised  while  the  uterus  is  contracted.  If  the  fundus  is  relaxed 
it  is  a  relatively  easy  matter  to  indent  it,  and  when  once  an  indentation 
has  occurred  it  is  a  still  easier  matter  to  continue  this  indentation  into 
an  incomplete  inversion  of  the  uterus.  In  the  cases  which  have  occurred 
and  been  seen  by  the  author  this  has  been  the  etiology. 

It  must  ])e  admitted  that  with  a  placenta  adherent  to  a  relaxed  fundus, 
traction  on  the  cord  which  used  to  be  practised  by  ignorant  midwives 
could  produce  inversion.    This  has  not  been  met  with  in  my  experience. 

A  number  of  obser^■e^s  have  reported  cases  of  spontaneous  inversion 


PLATE    IX 


Complete  Inversion  of  Uterus. 


POSTPARTUM  HEMORRHAGE  593 

of  the  uterus,  in  which  a  relaxed  fundus  fell  down  within  a  dilated  cervix 
under  the  influence  of  the  contraction  of  the  abdominal  muscles  or  the 
weight  of  an  adherent  placenta.  This,  however,  must  be  a  rare  occur- 
rence, and  it  is  wiser  to  consider  an  inversion  of  the  uterus  as  usually  the 
result  of  mismanagement  on  the  part  of  the  obstetrician. 

In  g^Tiecology  one  occasionally  meets  with  a  case  in  which  a  submucous 
fibroid  attached  to  the  fundus  of  the  uterus  has  been  gradually  expelled 
through  the  cendx  which  it  has  slowly  dilated  and  has  drawn  the  fundus 
after  it,  producing  an  inversion  of  the  fundus.  This,  however,  is  a  gradual 
process,  has  little  connection  ■v^'ith  the  acute  inversion  of  obstetrics,  and 
will  not  further  concern  us  here. 

Signs  and  Symptoms. — The  diagnosis  of  inversion  of  the  uterus  .after 
delivery  is  usually  made  by  noting  the  absence  or  cupping  of  the  fundus 
above,  by  the  presence  of  a  mass  below,  usually  mth  the  placenta  adherent 
to  it  and  by  evidences  of  shock  and  hemorrhage  presented  by  the  patient. 
The  symptom  of  shock  in  the  complete  variety  of  inversion  of  the  uterus 
is  quite  pronounced  and  usually  leads  one  to  seek  the  cause.  The  amount 
of  hemorrhage  varies  in  different  cases,  but  in  those  seen  by  the  author 
it  has  been  greater  in  the  incomplete  variety  where  the  placenta  had  been 
expelled,  but  in  the  process  a  portion  of  the  uterus  had  been  carried  down 
toward  the  cervix,  preventing  normal  contraction  of  the  uterine  body. 
In  the  case  illustrated  in  Plate  IX,  where  the  inversion  was  complete 
and  the  placenta  was  adherent  to  the  inverted  fundus,  there  was  rela- 
tively little  hemorrhage,  shock  being  the  pronounced  symptom.  The 
physical  signs  were  characteristic.  The  fundus  could  not  be  felt  through 
the  abdominal  wall,  but  protruding  from  the  vulva  was  a  mass  covered 
by  the  placenta  with  amniotic  surface  outward. 

Progrnosis. — This  depends  upon  its  recognition  and  prompt  treatment. 
If  the  condition  is  recognized  at  once,  replacement  is  usually  easy  and  the 
prognosis  favorable.  Neglected  cases  have  a  high  mortality  from  sepsis, 
hemorrhage,  etc.  In  a  series  of  54  cases  reported  by  Winckle  there  were 
12  deaths.    Hirst  reports  6  cases  "^-ith  no  deaths. 

In  35,000  consecutive  deliveries  at  the  Sloane  Hospital  only  1  case 
of  complete  inversion  of  the  uterus  occurred.  This  is  pictured  in 
Plate  IX,  and  had  a  favorable  termination. 

Treatment. — Inversion  of  the  uterus  is  so  often  the  result  of  mismanage- 
ment of  the  third  stage  of  labor  that  the  prophylactic  treatment  is  most 
important,  especially  the  precaution — Do  not  attempt  Credes  expression  of 
the  placenta  icith  a  relaxed  fundus.  Another  precaution  which  it  hardly 
seems  necessary  at  the  present  day  to  state  is:  Do  not  attempt  delivery 
of  the  placenta  by  traction  on  the  cord.  Certain  cases  of  partial  inversion 
of  the  uterus  will  reduce  themselves  as  the  uterus  contracts. 

In  the  active  treatment  of  inversion,  the  indication  is  the  replacement 
of  the  fundus  as  soon  as  possible,  before  the  cervLx  has  contracted  firmly 
and  strangulation  is  threatened.  The  method  varies  according  as  to 
whether  the  placenta  is  still  attached  or  whether  it  has  been  separated 
and  expelled.  In  order  to  have  the  mass  to  be  replaced  as  small  as  pos- 
sible, the  better  plan  is  usually  to  remove  the  placenta  manually  before 
38 


594  HEMORRHAGE 

attempting  reduction  of  the  fundus.  After  the  placenta  has  been  removed, 
if  the  inversion  is  incomplete,  the  obstetrician  with  one  hand  working 
within  the  cavity  of  the  uterus  and  the  other  through  the  abdominal 
wall,  can  usually  by  so-called  "taxis"  restore  the  original  shape  of  the 
uterus.  If  the  inversion  is  complete,  the  problem  is  to  carry  back  through 
the  cervical  ring  the  larger  uterine  body.  The  plan  of  procedure  is  to 
try  to  replace  first  the  part  which  came  through  last,  i.  e.,  by  working 
with  the  fingers  on  one  side  of  the  uterine  mass  near  the  cervix,  try  to 
carry  back  through  the  cervical  ring  a  part  of  the  lower  uterine  segment. 
If  once  a  start  is  made  and  a  portion  of  the  uterus  is  replaced,  the  rest  of 
the  uterus  usually  follows  easily. 

With  the  inversion  replaced  the  next  problem  is  its  maintenance.  For 
this  purpose  it  is  advisable  to  pack  the  uterus  with  gauze.  The  above 
treatment  is  applicable  to  cases  seen  and  diagnosed  immediately  after 
the  occurrence  of  the  accident.  If  the  diagnosis  is  delayed  or  the  con- 
dition is  neglected,  the  cervix  will  contract  firmly,  and  the  inverted 
uterus  tend  to  slough  with  the  danger  of  septic  peritonitis.  Sometimes 
the  inversion  becomes  chronic  without  sloughing  or  infection,  but  this 
belongs  within  the  realm  of  gynecology  and  will  not  be  further  discussed 
here.  Inversion  found,  however,  at  any  time  during  the  obstetric  month, 
does  demand  our  consideration,  and  the  first  method  to  be  tried  is  that 
of  taxis  with  the  woman  under  anesthesia  similar  to  the  method  already 
described  for  the  acute  cases.  If  taxis  fails,  several  operative  procedures 
are  at  command.  These  consist  in  dividing  the  cervical  ring  posteriorly 
(Hirst),  anteriorly  (Peterson),  or  both  anteriorly  and  posteriorly  together 
with  the  lower  uterine  segment  (Spindli). 

After  replacement  of  the  uterus  these  incisions  are  of  course  sutured. 

Puerperal  Hemorrhages. — Under  this  term  are  included  all  profuse 
hemorrhages  from  the  parturient  canal  occurring  at  any  time  from  the 
end  of  the  first  twenty-four  hours  till  the  end  of  the  obstetric  month. 

Etiology. — The  cause  of  puerperal  hemorrhages  may  be  either  without 
or  within  the  uterus.  The  causes  acting  from  without  the  uterus  usually 
do  so  either  by  causing  a  sudden  relaxation  of  the  organ,  as  some  strong 
emotion,  grief,  anger,  fear,  etc.,  or  by  interfering  with  uterine  contraction 
as  overdistention  of  the  bladder  or  rectum,  especially  the  former.  The 
()^'erdistention  of  these  viscera  often  acts  by  causing  version  or  flexion 
with  congestion  and  retention  of  blood-clots. 

Causes  acting  from  within  the  uterus  may  be  either  within  the  uterine 
wall  or  within  the  uterine  cavity,  and  both  act  by  interfering  with  normal 
uterine  contractions.  Those  within  the  uterine  wall  are  chiefly  fibro- 
myomata. 

The  most  common  cause  of  puerperal  hemorrhages  is  something  within 
the  uterine  cavity,  as  retained  portions  of  placenta,  a  placenta  succen- 
turiata,  blood-clots,  polypi,  etc.  Unless  a  uterus  is  empty  it  cannot  con- 
tract firmly  and  hemorrhage  is  a  natural  sequel.  Portions.of  the  placenta 
and  blood-clots  usually  undergo  putrefacti\e  changes  and  occasion  a  rise 
of  temperature  and  other  evidences  of  infection.  Occasionally,  h()we\er, 
a  portion  of  placenta  is  so  firmly  adherent  to  the  uterus  that  it  retains  its 


PUERPERAL  HEMORRHAGES  595 

vitality,  becomes  more  or  less  pedunculated,  blood  is  deposited  about  it 
and  becomes  organized  and  a  so-called  placental  polypus  is  formed,  which 
is  nourished  as  is  a  fibroid  polypus  through  the  vessels  of  its  pedicle. 
This  placental  polypus  may  remain  in  the  uterine  cavity  for  months, 
causing  hemorrhages,  but  without  infection. 

Treatment. — Causes  of  puerperal  hemorrhages  acting  from  without 
the  uterus,  such  as  sudden  strong  emotions,  overdistended  bladder  and 
rectum  should  be  eliminated  h\  keeping  the  patient  quiet  and  by  proper 
attention  to  her  avenues  of  elimination. 

Since  the  most  common  cause  of  puerperal  hemorrhages  is  something 
abnormal  within  the  uterine  cavity,  this  should  be  explored  under  anes- 
thesia and  emptied.  This  can  usually  be  done  with  the  fingers,  aided  if 
necessary  by  a  loop-ended  sponge-holder,  which  can  be  used  both  as  a 
firm,  blunt  curette  and  as  a  placenta  forceps.  If  the  uterine  cavity  is 
then  freed  from  all  debris  with  a  gentle  douche  of  sterile  salt  solution, 
and  the  patient  is  kept  quiet  until  involution  is  complete,  the  hemor- 
rhage is  not  likely  to  recur. 

Involution  in  these  cases  is  usually  aided  by  the  administration  of 
ergot.  If  the  hemorrhages  are  caused  by  the  presence  of  fibromyomata 
in  the  uterine  wall,  the  indication  is  usually  to  hasten  involution  by  the 
administration  of  ergot  and  the  application  of  the  ice-bag  to  the  abdo- 
men over  the  fundus  and  to  leave  the  decision  as  to  the  treatment  of 
the  fibroid  until  the  puerperium  is  passed.  Occasionally  fibromyomata 
in  the  uterine  wall  not  only  cause  puerperal  hemorrhage,  but  as  a  result 
of  disturbed  circulation  due  to  the  labor,  undergo  degenerative  changes, 
become  infected  and  demand  removal  or  hysterectomy  even  during  the 
puerperium. 


CHAPTER  XVIII. 
PYELITIS  COMPLICATING  PREGNANCY. 

During  the  last  few  years  it  has  become  recognized  that  inflammation 
of  the  pelvis  of  the  kidney  is  a  not  infrequent  complication  of  pregnancy 
and  the  puerperium  and  produces  symptoms  which  in  the  past  have  led 
to  many  errors  of  diagnosis. 

The  literature  of  the  subject  prior  to  1904  is  very  meager  and  mostly 
in  French,  but  since  that  date  many  articles  have  appeared  reporting 
individual  cases  so  that  now  the  list  of  recorded  cases  is  large  and  steadily 
increasing. 

The  condition  Avas  first  recognized  and  described  in  1S41  by  Rayer, 
whose  Traite  dc  maladies  des  Riens,  vol.  iii,  p.  112  et  241,  contains 
a  chapter  on  Rapports  de  la  pyelite  et  de  la  grossesse. 

He  evidently  recognized  pregnancy  as  a  cause  of  renal  distention 
and  inflammation  but  contrary  to  the  present  accepted  view,  considered 
the  pyelitis  as  secondary  to  a  cystitis. 

That  pyelitis  is  not  a  rare  complication  of  pregnancy  and  the  puer- 
perium is  evidenced  by  the  fact  that  from  1900  to  1910  in  his  service  at 
the  Sloane  Hospital  and  in  his  private  consulting  practice  in  New  York 
and  its  suburbs,  the  writer  met  with  23  cases,  17  occurring  during 
pregnancy  and  G  during  the  puerperium. 

Etiology. — Reblaub,  at  the  surgical  congress  in  1892,  first  gave  the  true 
etiology  and  pathology,  i.  e.,  ureteral  compression  and  infection. 

As  early  as  1877  Chamberlain^  called  attention  to  the  fact  that  in  preg- 
nancy the  kidney  is  congested  and  the  ureter  dilated  and  for  this  reason 
is  more  liable  to  infection. 

The  fact  of  frequent  ureteral  dilatation  in  pregnancy  has  been  verified 
at  autopsy  by  many  observers,  among  whom  may  be  mentioned  Stadfeld, 
Olshausen,  Loelein  and  others. 

Stadfeld,  in  16  autopsies  on  pregnant  women,  found  the  ureter  dilated 
on  one  or  both  sides  in  9. 

Olshausen,  in  34  autopsies  on  pregnant  women,  found  dilated  ureter 
in  25  cases. 

L'reteral  compression  and  consequent  dilatation  is  much  more  apt  to 
occur  on  the  right  side  than  on  the  left.  In  the  25  cases  in  Avhich 
Olshausen  found  dilated  ureters,  the  dilatation  was  bilateral  in  13,  and 
unilateral  in  12,  and  of  these  12  there  were  10  right-sided  and  2  left. 

This  is  of  importance  in  connection  with  the  marked  predominance 
of  right-sided  pyelitis  in  pregnancy  as  compared  with  the  left.  The 
accompanying  drawing  (Plate  X)  from  an  autopsy  on  one  of  the  author's 

1  Amer.  Jour.  Obstet.,  1877,  p.  177. 
(596) 


PLATE  X 


Dilatation  of  Riglit  Ureter  in  Patient  Recently  Pregnant. 


ETIOLOGY  597 

cases,  dying  soon  after  confinement,  without  pyelitis,  demonstrates  the 
condition  of  right  ureteral  dilatation. 

Experiments  on  animals  by  Halbertsma  and  others  have  shown  that 
the  urine  is  excreted  under  low  pressure.  Halbertsma^  showed  that  the 
weight  of  5  grams  compressing  the  ureter  of  a  dog  over  a  surface  of 
8  mm.  is  sufficient  to  hold  back  a  column  of  urine  400  mm.  in  height. 

Ludwig  demonstrated  that  the  pressure  in  the  renal  pelvis  normally 
does  not  exceed  10  mm.  of  mercury.  It  requires,  therefore,  but  little 
compression  of  the  ureter  to  retard  the  current  and  favor  ureteral 
dilatation. 

To  explain  the  greater  frequency  of  dilatation  of  the  right  ureter  over 
the  left,  many  suggestions  have  been  made : 

1.  The  rotation  of  the  uterus  on  its  long  axis  from  left  to  right,  forward, 
places  the  uterus  and  its  contents  more  in  the  right  oblique  diameter  of 
the  pelvis  than  in  the  left  and  thus  exerts  more  pressure  upon  the  right 
ureter  than  on  the  left.  As  to  the  causes  of  this  rotation  of  the  uterus, 
it  may  be  mentioned  that  as  the  uterus  rises  out  of  the  pelvis  it  is  deflected 
from  the  median  line  by  the  promontory  of  the  sacrum  and  therefore 
lies  in  one  or  other  oblique  diameter.  The  presence  of  the  rectum  on  the 
left  side  of  the  pelvis  naturally  favors  deflection  to  the  opposite  side. 
Also,  as  the  uterus  rises  into  the  abdomen  the  sigmoid  flexure  of  the  colon, 
often  distended,  tends  to  lie  behind  the  left  side  of  the  uterus  and  still 
further  favors  the  right  obliquity  of  that  organ.  According  to  Guy  on, 
uterine  and  ovarian  tumors,  wdien  movable,  tend  to  be  displaced  to  the  right. 

2.  The  greater  prominence  of  the  right  over  the  left  common  iliac 
artery  at  the  brim  of  the  pelvis  exposes  the  right  ureter  to  greater  press- 
ure between  the  uterus  and  the  iliac  artery  of  that  side. 

3.  In  the  later  months  of  pregnancy  the  greater  frequency  of  the  fetal 
head  in  the  right  oblique  diameter  of  the  pelvis  increases  the  frequency 
of  pressure  upon  the  right  ureter. 

4.  The  pregnant  uterus  as  it  grows  tends  to  displace  the  ureters  to  the 
sides  of  the  pelvis  against  which  it  compresses  them.  As  the  uterus 
usually  develops  more  to  the  right  than  to  the  left,  the  compression 
is  usually  greater  on  that  side. 

On  account  of  the  greater  tone  in  the  uterine  and  abdominal  walls 
in  primigravidpe,  it  would  naturalh'  be  expected  that  more  ureteral 
compression,  and  hence  more  cases  of  pyelitis  would  occur  in  primi- 
gravidse  than  in  multigravidse,  and  that  was  borne  out  in  the  experience 
of  the  author,  there  being  among  the  17  antepartum  cases  11  primigravidse 
and  6  multigravidse. 

It  has  been  noted  that  anything  tending  to  increase  the  size  of  the 
pelvic  contents,  i.  e.,  twins,  hydramnios,  uterine  or  ovarian  tumors 
associated  with  pregnancy,  favors  the  tendency  to  ureteral  compression 
and  dilatation. 

Injection  of  the  Urinary  Tract  Above  the  Point  of  Compression. — From 
the  frequency  with  which  the  Bacillus  typhosus  appears  in  the  urine  of 

1  Volkmann's  Samm.  klin.  Vprtrag,  Januarj',  1882,  N.  212. 


598  PYELITIS  COMPLICATIXG  PREGXANCY 

typhoid  fever  patient.s  and  from  experiments  on  animals  it  would  seem 
that  in  many  infeetive  processes,  provided  the  urinary  tract  is  unob- 
structed, ortjanisms  may  i)e  eliminated  1).\  the  urine  without  ai)precial)le 
injury  to  the  renal  tract. 

On  the  other  hand,  the  experiments  on  animals  by  Reblaub  and  Bonneau 
show  that  after  an  aseptic  ligature  of  the  ureter  the  injection  of  either 
streptococci  or  colon  bacilli  into  a  distant  part  of  the  body  can  produce  a 
pyonephrosis. 

From  the  above  it  seems  evident  that  a  renal  tract,  in  which  there  is 
compression  of  the  ureter  or  ureters,  is  much  more  liable  to  infection 
than  one  which  is  unimpeded. 

In  pregnancy  we  have  on  the  one  hand  a  urinary  tract  which  is  com- 
pressed, as  shown  by  the  frequency  of  dilated  ureters  in  that  condition, 
and  on  the  other  hand  we  have  a  larger  amount  of  toxic  material  than 
normal  to  be  eliminated.    Hence  the  frequency  of  pyelitis. 

In  most  cases  of  pyelitis  complicating  ])regnancy  and  the  puerperium 
the  disease  is  primarily  right-sided,  although  if  the  attack  is  severe  and 
prolonged  the  left  kidney  is  occasionally  involved  secondarily. 

In  the  writer's  23  cases  all  but  1  were  primarily  right-sided  and  in 
none  was  the  involvement  of  the  left  kidney  marked. 

As  bearing  on  this  subject  the  case  reported  by  Kouwer  is  one  of 
interest. 1  In  Case  I  of  his  series  the  obliquity  of  the  uterus  at  seven 
months  was  distinctly  to  the  left,  and  here  the  pyelitis  was  primarily 
left-sided.  When  the  position  of  the  uterus  was  corrected  the  symptoms 
of  the  pyelitis  suddenly  disappeared.  In  a  series  of  62  reported  cases 
the  left  side  was  primarily  infected  but  six  times.  In  a  few  cases  it  has 
been  bilateral. 

The  infecting  organism  in  the  pyelitis  of  pregnancy  is  usually  the  colon 
bacillus,  and  often  a  diarrhea  or  intestinal  disturbance  has  preceded  the 
attack. 

Mnay,  on  the  other  hand,  found  in  one  of  his  cases  the  streptococcus, 
and  in  a  case  reported  by  Lop  the  gonococcus  was  found. 

The  period  of  pregnancy  at  which  pyelitis  is  most  likely  to  occur  is, 
judging  from  the  author's  cases,  between  five  and  eight  months.  In  the 
17  cases  of  the  author's  in  which  the  pyelitis  appeared  during  pregnancy, 
it  occurred  at  five  months  in  7;  at  six  months  in  3;  at  seven  months  in 
3;  at  eight  months  in  2.    In  2  cases  it  appeared  near  term. 

In  a  case  referred  to  by  Kendirdjy-  it  occurred  at  two  and  a  half 
months. 

Clinical  Course. — Although  occasionally  the  onset  of  the  disease  is 
insidious,  with  scarcely  any  rise  of  temperature  and  slight  pain,  and  the 
condition  is  discovered  accidentally  by  examination  of  the  urine,  as  a 
rule  the  onset  is  sudden  and  marked,  presenting  the  following  symptoms: 
Pain  in  the  right  lumbar  region;  a  rise  of  temperature  often  accompanied 
by  a  rigor;  irritability  of  the  bladder. 

1  Pyelonephritis  en  zwangerschap  Niederl.  Tijdschr.  v  Geneesk.,  Amsterdam,  1904,  2  r., 
xl,  d.  2,  539-549. 

-  Gazette  de  hopitaiix  civils  et  niilitares,  1904,  xxvii. 


CLINICAL  COURSE 


599 


Pain  in  the  Right  Luinhar  Region. — Although  very  rarely  the  left 
kidney  is  the  organ  chiefly  involved  and  near  it  the  pain  is  located, 
and  although  occasionally  the  pain  seems  to  be  general  over  the  abdomen, 
the  typical  picture  of  pyelitis  is  pain  and  tenderness  in  the  region  of  the 
right  kidney.  This  pain  is  sometimes  very  severe  and  agonizing,  some- 
times only  elicited  by  palpation  or  motion.  The  pain  often  follows  the 
course  of  the  ureter  from  kidney  to  bladder.    It  is  often  intermittent. 


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Fig.  369.- 


-Typical  case  of  pyelitis.     Pregnancy  seven  months  advanced, 
puerperjum  at  term. 


Normal 


Rise  of  Temperature. — Most  cases  show  a  rise  of  temperature  ranging 
from  102°  to  104°  F.,  often  accompanied  by  one  or  more  rigors.  In  mild 
cases,  under  appropriate  treatment  of  the  condition,  the  temperature 
subsides  in  from  four  to  seven  days,  but  in  more  severe  types  there  are 
recurrences  which  may  extend  the  temperature  over  several  weeks.  The 
accompanying  temperature  chart  of  one  of  the  author's  cases  illustrates 
an  average  (see  Fig.  369). 


600  PYELITIS  COMPLICATIXC  PREGNANCY 

If  the  kidney  .substance  l)ect)nies  invohed  tlie  temperature  continues 
higher  and  rigors  are  more  frequent  and  pronounced. 

The  pain  over  the  ki(hiey  and  rise  of  temperature,  with  or  without 
rigors,  are  usually  synchronous  and  correspond  with  the  obstruction  of 
the  ureter  and  retention  of  purulent  urine  above  the  region  of  obstruction. 

With  the  overcoming  of  the  obstruction  and  establishment  of  a  free 
flow  from  kidney  to  bladder  the  pain  and  temperature  usually  subside. 

During  the  height  of  pain  and  temperature  the  urine  may  show  no  pus, 
but  with  the  subsidence  of  the  pain  and  temperature  pus  cells  usually 
appear. 

llecurrences  of  the  pyelitis  with  rise  of  temperature,  pain  and  other 
evidences  of  the  condition  may  appear  after  several  weeks  of  apparent 
health. 

Irritability  of  the  Bladder. — Among  the  early  symptoms  of  pyelitis  in 
pregnancy  are  frequent  and  painful  micturition,  perhaps  misleading  to 
the  diagnosis  of  cystitis. 

In  some  cases  the  micturition,  although  frequent,  is  accompanied  by 
little  pain.  If  the  pyelitis  is  severe  and  the  discharge  of  pus  profuse  the 
inflammation  may  descend  along  right  ureter  to  the  bladder,  and  thence 
up  along  left  ureter  to  the  left  kidney,  the  cystitis  in  this  case  being 
secondary  to  the  pyelitis.  AYhile  in  a  cystitis  arising  during  pregnancy 
or  the  puerperium  from  many  different  sources  of  infection,  the  inflam- 
mation may  extend  upward  along  the  ureters  and  produce  pyelitis  the 
typical  pyelitis  of  pregnancy,  in  the  opinion  of  the  author  and  most 
French  authorities,  is  a  descending  infection  and  involves  the  bladder 
only  secondarily. 

It  is  but  fair  to  state  in  this  connection,  however,  that  Opitz  and 
many  Germans  regard  the  infection  as  ascending  even  if  no  cystitis  is 
present.^ 

The  urine  is  acid,  sp.  gr.  1.008  to  1.012,  at  first  may  contain  only  a  trace 
of  albumin  and  perhaps  a  few  casts,  to  be  soon  followed  by  pus  cells, 
renal  epithelium,  and  l)acteria.  The  pus  cells,  as  stated  above,  are  usually 
more  abundant  as  the  pain  and  temperature  subside.  The  urine  after 
filtration  often  shows  no  albumin.  The  urine  often  contains  pus  cells 
for  a  month  or  more  after  the  constitutional  symptoms  have  subsided. 
In  one  of  the  author's  cases  the  urine  did  not  become  absolutely  free  from 
pus  until  the  baby  Avas  nine  months  old. 

The  general  condition  of  the  patient,  provided  the  pyelitis  is  unilateral, 
continues  good  for  a  considerable  time  in  spite  of  the  high  temperature. 
The  pulse,  although  rapid  during  the  height  of  the  temperature,  soon 
falls  below  100. 

If  the  disease  becomes  bilateral  the  general  condition  of  the  patient 
begins  to  deteriorate,  as  sho^Ti  by  emaciation,  pallor,  loss  of  strength,  and 
appetite. 

Diagnosis. — The  diagnosis  of  the  condition,  although  extremely  impor- 
tant, has  until  recently  been  largely  overlooked.    IMany  cases  of  pyelitis 

1  Zeitschrift  fur  Geburtshulfe  und  Gynakologie,  Bd.  xv,  S.  209. 


DIAGNOSIS  601 

in  pregnancy  have  undoubtedly  been  mistaken  for  appendicitis,  typhoid 
fever,  cystitis,  or  salpingitis. 

In  many  cases  the  diagnosis  is  easy  if  the  possibility  of  the  condition 
is  borne  in  mind.  Pain  and  tenderness  in  the  region  of  the  kidney,  a  rise 
of  temperature,  an  irritable  bladder  and  an  acid  urine  containing  pus 
may  point  at  once  to  the  diagnosis  of  pyelitis.  On  the  other  hand  it 
must  be  remembered  that  palpation  of  the  abdominal  viscera  of  a  woman 
pregnant  from  five  to  eight  months  is  not  an  easy  matter,  and  these  other 
diseases  often  give  symptoms  which  closely  resemble  those  of  pyelitis. 

In  two  of  the  author's  cases  the  point  of  greatest  tenderness  corre- 
sponded closely  with  the  McBurney  point,  and  it  was  only  by  a  careful 
examination  of  the  urine  that  the  correct  diagnosis  was  made.  It  has 
seemed  to  the  author  in  studying  his  series  of  cases,  that  the  leukocyte 
count  in  the  cases  of  pyelitis  resembling  appendicitis  was  lower  than 
would  be  expected  in  an  appendicitis  case  correspondingly  ill.  The  reason 
for  the  point  of  tenderness  corresponding  closely  with  the  McBurney 
point  seemed  to  be  that  pressure  at  this  point  forced  the  uterus  back 
against  the  inflamed  ureter  and  this  increased  the  pain. 

One  of  the  author's  cases  presented  symptoms  which  at  first  suggested 
typhoid  fever.  She  had  an  irregular  fever  for  several  days,  with  an  occa- 
sional epistaxis.  For  three  days  prior  to  his  visit  she  had  complained  of 
pain  in  the  right  lumbar  region.  The  diagnosis  was  made  b}'  finding  the 
Widal  test  negative  and  the  urine  acid,  with  pus  cells,  renal  epithelium, 
bacteria,  and  a  trace  of  albumin.  Her  epistaxis  was  probably  explained 
by  the  amenorrhea  of  pregnancy. 

The  symptoms  of  pyelitis  in  the  early  stages  often  resemble  those  of 
a  cystitis,  but  the  acidity  of  the  urine,  the  location  of  the  pain  in  pyelitis 
being  usually  in  the  region  of  the  kidney  and  ureter  hence  higher  than 
is  the  rule  in  cystitis;  the  higher  temperature;  the  less  vesical  tenesmus 
in  pyelitis  and  the  fact  that  in  pyelitis  150  to  200  c.c.  of  boric  acid  solu- 
tion can  usually  be  injected  into  the  bladder  with  very  little  discomfort 
to  the  patient,  usually  distinguishes  the  condition  from  a  cystitis.  It 
has  already  been  stated  that  a  cystitis  may  arise  as  a  secondary  result 
of  the  pyelitis. 

The  differential  diagnosis  between  pyelitis  and  salpingitis  can  usually 
be  made  by  the  history,  a  bimanual  examination,  and  the  careful  examina- 
tion of  the  urine. 

It  will  thus  be  seen  that  the  diagnosis  of  pyelitis  complicating  preg- 
nancy can  usually  be  made  if  there  is  remembered  the  possibility  of  its 
occurrence;  the  cardinal  symptoms,  viz.,  pain  in  region  of  the  kidney 
(usually  the  right),  a  rise  of  temperature  and  bladder  irritation,  and  by 
a  careful  examination  of  the  urine,  chemical,  microscopic,  and  bacterio- 
logical. 

Cystoscopy  and  ureteral  catheterization  are  sometimes  of  aid  in 
diagnosis. 

In  the  case  of  Price,^  a  catheter  introduced  into  the  right  ureter  passed 

1  Med.  Record,  1904,  xxvi,  379-385. 


602  PYELITIS  COMPLICATING  PREGNANCY 

but  a  short  distaiur  and  l)ucklcd.  It  passed  easily  into  tlie  left  ureter. 
The  cystoscope  showed  diseoloration  about  the  right  ureteral  orifiee. 
In  this  ease  al)()rti()u  was  induced  and  a  month  later  a  catheter  passed 
alon<i;  the  right  ureter  without  difficulty. 

Pyelitis  conii)licating  the  puerperium  may  arise  either  as  a  descending 
infection  like  the  pyelitis  of  pregnancy,  or  as  an  ascending  infection 
secondary  to  a  cystitis.  Arising  in  either  of  these  two  ways  it  is  often 
mistaken  for  uterine  infection  and  the  uterus  subjected  to  many  useless 
indignities.  The  usual  rules  of  diagnosis  as  applied  to  pyelitis  complicat- 
ing pregnancy  will  usually  solve  the  problem  in  the  puerperium. 

Prognosis. — The  prognosis  in  pyelitis  complicating  pregnancy  varies 
greatly.  If  there  has  been  no  previous  disease  of  the  kidney  and  the 
attack  is  mild  and  unilateral  the  prognosis  is  usually  good. 


Fig.  .370. — Kidney  removed  from   case  whose  temperature  chart  is  shown  in  Fig.  371. 

^Yhen  the  disease  is  bilateral  and  severe  there  is  always  a  possibility 
of  its  extending  to  the  kidney  substance,  perhaps  producing  multiple 
abscesses  and  demanding  nephrectomy,  as  occurred  in  one  of  the  author's 
cases  (see  Figs.  370  and  371). 

As  a  rule  the  urine  shows  evidence  of  the  disease  for  several  weeks 
after  the  subsidence  of  the  constitutional  symptoms.  The  possibility 
of  a  recurrence  of  the  attack  during  the  same  pregnancy  or  during  the 
puerperium  should  be  borne  in  mind.  This  has  occurred  in  the  author's 
experience. 

The  condition  may  also  recur  in  subsequent  pregnancies,  as  reported 
by  Vinay,  who  has  seen  it  recur  in  three  successive  pregnancies.  Cases 
are  reported  in  which  several  months  after  childbirth  and  after  apparent 
general  recovery  pyelonephritis  occurred  which  demanded  nephrectomy. 


TREATMENT  603 

The  above  represents  the  dark  side  of  the  picture  and  is  exceptionaL 

The  rule  is  that  the  attack  is  mild;  under  appropriate  treatment  lasts 
but  a  few  days;  the  patient  goes  to  term  and  enjoys  a  normal  puerperium. 

It  is  possible  that  a  pregnant  as  well  as  a  non-pregnant  patient  may 
have  a  pyelitis  resulting  from  a  calculus  or  from  a  tubercular  inflamma- 
tion, but  these  do  not  belong  in  the  class  now  under  discussion. 

Treatment. — In  the  vast  majority  of  cases  the  medical  treatment  of 
rest  in  bed,  drinking  large  quantities  of  water,  fluid  diet  and  a  urinary 
antiseptic  meets  the  indications  and  is  followed  by  the  recovery  of  the 
patient.  Often  within  forty-eight  hours  after  beginning  the  treatment 
the  temperature  and  pulse  return  to  normal  and  the  patient  feels  com- 
paratively comfortable,  although  the  urine  still  shows  pus.  The  urinary 
antiseptic  which  has  given  the  author  the  greatest  satisfaction  is  urotropin 
given  in  the  dose  of  gr.  v  four  times  a  day.  The  pain  in  some  cases  is 
very  intense,  and  although  this  is  somewhat  relieved  by  an  ice-bag  over 
the  kidney,  it  is  usually  necessary  to  administer  some  preparation  of 
opium.  The  cause  of  the  pain  is  the  damming  back  of  the  purulent  urine 
in  the  kidney  and  ureter,  hence  the  pain  is  often  most  acute  before  pus 
appears  in  the  urine. 

The  rigor  and  the  rise  of  temperature  belong  with  the  pain  in  this 
period  of  obstructed  ureter.  With  the  overcoming  of  the  obstruction  by 
the  flushing  treatment  above  mentioned,  the  pain  and  temperature 
subside  and  pus  appears  in  the  urine,  or  if  present  before,  usually  shows 
an  increase.  The  giving  way  of  the  obstruction  in  the  ureter  under  the 
influence  of  increased  fluid  pressure  above  may  be  only  temporary,  and 
recurrences  of  the  retention  with  pain,  fever  and  rigor  are  frequent, 
the  purulent  urine  each  time  accumulating  until  its  pressure  is  suffi- 
cient to  overcome  the  resistance  of  the  obstruction  in  the  ureter,  when  a 
discharge  takes  place  into  the  bladder  with  a  subsidence  of  the  acute 
symptoms. 

In  one  of  the  author's  cases  this  occurred  at  a  regular  interval  of  forty- 
eight  hours  for  a  number  of  days,  so  that  the  rigor  and  high  temperature 
every  other  day  with  normal  temperature  and  pulse  on  the  intervening 
day  gave  a  strong  resemblance  to  malarial  infection. 

In  many  reported  cases  the  injection  of  150  to  200  c.c.  of  boric  acid  solu- 
tion into  the  bladder,  as  recommended  by  Pasteau,  has  seemed  to  stimu- 
late increased  secretion  in  the  kidney  with  the  overcoming  of  the  obstruc- 
tion and  a  relief  of  the  symptoms.  SippeP  advises  relief  of  pressure  on 
the  inflamed  kidney  and  ureter  by  having  the  patient  lie  on  the  opposite 
side.    He  reports  marked  relief  from  this  mode  of  treatment. 

As  the  cause  of  the  obstruction  and  infection  of  the  urinary  tract  is 
the  advancing  pregnancy,  the  question  naturally  arises:  Should  not  the 
pregnancy  be  terminated?  In  answering  this  question  many  phases  of 
the  subject  have  to  be  considered. 

Most  of  the  cases  recover  under  medical  treatment  and  the  pregnancy 
goes  to  term  and  terminates  in  a  normal  labor  and  puerperium. 

1  Zentralblatt  fiir  Gynakologie,  1905,  No.  37. 


604 


PYELITIS  COMPLICATING  PREGNANCY 


On  the  other  hiuul,  oecasioiuilly,  us  oecurred  in  one  of  the  author's  cases, 
the  pyelitis  increases  in  severity  until  it  alone  induces  the  labor. 

In  most  cases  tlie  pyelitis  rapidly  inii)rove^  after  the  uterus  is  emptied 
and  the  pressure  removed.  On  the  other  hand,  in  some  the  pyelitis  first 
appears  at  term  or  in  the  puerperium.  In  a  few  cases  the  pyelitis  extends 
to  the  renal  substance  and  becomes  a  suppurative  pyelonephritis,  as 
occurred  in  the  fifth  case  which  came  under  the  author's  observation, 
whose  temperature  chart  appears  in  Fig.  371. 


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Fig.  371.- 


-Case  of  suppurative  pyelonephritis  resulting  from  pyelitis, 
shown  in  Fig.  370. 


The  kidney  is 


Judging  from  the  writer's  experience,  this  extension  to  the  kidney  sub- 
stance is  more  likely  to  occur  when  the  pyelitis  begins  near  '.erm  or  in 
the  puerperium. 

In  some  cases  the  passage  of  the  ureteral  catheter  has  seemed  to 
overcome  the  obstruction  in  the  ureter  and  to  favor  drainage  from  the 
kidney.  The  injection  of  20  per  cent,  argyrol  solution  through  the 
ureteral  catheter  has  been  strongly  recommended  by  some.  It  must 
always  be  borne  in  mind,  however,  that  any  trauma  of  the  urinary  tract 
favors  a  further  spread  of  the  colon  bacillus  infection. 


TREATMENT  605 

Considering  all  these  facts  the  author  believes: 

1.  That  interruption  of  the  pregnancy  before  the  period  of  viability 
of  the  child  is  very  seldom  indicated.  In  only  2  of  his  17  cases  was 
premature  labor  induced. 

2.  That  when  the  pyelitis  occurs  between  the  fifth  and  seventh  month 
in  a  kidney  previously  healthy,  a  favorable  prognosis  under  medical 
treatment  is  justified  for  both  mother  and  child. 

On  the  other  hand,  realizing  that  the  condition  usually  improves  rapidly 
after  emptying  the  uterus  and  that  the  pyelitis,  if  it  continues,  sometimes 
extends  and  becomes  a  suppurative  pyelonephritis  demanding  nephrot- 
omy or  nephrectomy,  it  must  be  felt  that  if  the  fetus  has  reached  the 
age  of  viability,  and  in  spite  of  medical  and  eliminative  treatment,  the 
pyelitis  fails  to  improve,  interruption  of  the  pregnancy  is  not  only 
justified,  but  demanded. 

Disappointments  in  this  disease  are  not  uncommon.  Occasionally, 
after  a  subsidence  of  all  subjective  symptoms  for  a  week  or  perhaps 
several  weeks,  and  after  one  has  congratulated  himself  that  the  medical 
treatment  was  all  that  was  needed,  the  patient  will  have  a  recurrence 
of  all  the  acute  symptoms,  perhaps  with  greater  severity  than  before, 
and  necessitate  obstetrical  or  surgical  intervention.  In  these  cases  of 
recurring  or  long-continued  pyelitis  the  use  of  a  colon  bacillus  vaccine, 
preferably  an  autogenous  vaccine,  has  proved  of  great  value. 

In  the  severe  types  of  the  disease  occurring  during  pregnancy  and 
failing  to  respond  to  medical  treatment,  the  question  naturally  arises: 
Shall  the  kidney  be  operated  upon,  or  shall  the  uterus  be  emptied?  The 
author  believes  that  the  latter  procedure  should  usually  be  tried  first, 
especially  if  there  is  a  considerable  amount  of  pus  in  the  urine  and  the 
lesion  seems  to  be  chiefly  in  the  pelvis  of  the  kidney.  In  these  cases 
the  release  of  pressure  upon  the  ureter,  brought  about  by  emptying  the 
uterus,  favors  better  drainage  from  the  kidney  and  as  a  rule  the  condition 
rapidly  improves. 

On  the  other  hand,  in  some  cases  there  is  very  little  involvement  of  the 
pelvis  of  the  kidney,  but  the  colon  bacillus  infection  goes  right  to  the 
substance  of  the  kidney  and  here  operation  upon  the  kidney  rather  than 
the  uterus  is  indicated.  This  is  illustrated  by  the  following  case  occurring 
in  the  author's  service: 

Mrs.  L.,  a  primigravida,  aged  twenty-four  years,  was  admitted  to  the 
Sloane  Hospital,  November  12,  1914.  Her  last  menstrual  period  began 
May  20,  1914.  Four  days  before  admission  she  was  seized  with  a  sudden 
attack  of  pain  in  her  right  side.  This  pain  continued  until  admission  to 
the  hospital.  It  was  increased  by  deep  breathing  or  by  any  movement 
of  the  body.  It  seemed  to  shoot  down  toward  the  right  groin.  She 
suffered  with  frequent  and  painful  micturition,  and  on  the  night  preced- 
ing her  admission  to  the  hospital  she  had  a  rigor  with  temperature  103°  F. 

On  admission  to  the  hospital  a  catheterized  specimen  of  the  urine 
showed  no  pus  and  a  culture  showed  no  organisms.  The  urine  on  the 
fourth  day  after  admission  showed  pus  cells  and  10  per  cent,  albumin. 
The  patient  then  seemed  to  be  improving  under  urotropin  and  forced 


606 


PYELITIS  COMPLICATING  PREGNANCY 


fluids.  From  that  time  on,  however,  she  became  steadily  worse,  on  tlie 
tenth  and  eleventh  days  having  a  rigor  with  a  rise  of  temperaUire  to  105° 
F.  or  over,  as  seen  from  the  accompanying  chart  (see  Fig.  372).  It  was 
then  decided  to  remo\e  the  right  kidney,  which  was  done  by  the  author 
on  the  following  day.  The  kidney  is  shown  in  Figs.  373  and  374.  It 
showed  miiltij^le  small  abscesses  scattered  through  the  substance  of  the 
cortex.  A  culture  taken  from  these  abscesses  showed  a  pure  culture  of 
colon  bacilli. 


DAY  OF 
MONTH 


3       4 


9   '  10  I  11     12     13     U     15     Iti     17     IS     I'.l 


12     13     14     15     lli    17     IN     I'.l    20    2r  22    23    24  '  25    2(5    27    2S    2!»    30     1 


Fig.  372. — Opeiative  chart.     Mrs.  L.     iSiippurative  pyelonephriti?. 


The  patient  made  an  easy  recovery  from  her  operation  and  her  preg- 
nancy continjued  without  disturbance  until  January  7,  1915,  when  she 
came  back  to  the  hospital  suffering  with  a  p>elitis  of  the  left  kidney. 
She  went  into  spontaneous  labor  on  January  12,  and  was  delivered  after 
a  short  labor.  Her  course  during  the  puerperium  is  shown  in  Fig.  375. 
Her  pyelitis  of  the  left  kidney  subsided  on  the  seventh  day,  recurred 
between  the  fourteenth  and  sixteenth  days  and  then  disappeared.  When 
seen  five  months  later  the  urine  was  normal  and  the  j^atieiit  in  good 
condition.  The  continuation  of  the  high  temperature  with  rigors  and 
pain  and  tenderness  in  the  region  of  the  kidney  after  the  uterus  has  been 
emptied,  or  the  recurrence  of  these  symptoms  perhaps  months  after  the 


Fig.  373. — Kidney  of  Mrs.  L.,  showing  suppurative  pyelonephritis. 


Fig.  374. — Kidney  of  Mrs.  L.,  laid  open,  showing  suppurative  pyelonephritis. 


608 


PYELITIS  COMPLICATING  PREGNANCY 


delivery  and  in  s\nte  of  medical  treatment,  including  vaccines,  usually 
indicates  operation  upon  the  kidney  either  nephrotomy  or  nephrectomy. 
The  obstetrician  is  often  asked,  by  patients  who  have  had  a  pyelitis 
in  their  previous  pregnancy,  if  this  is  likely  to  recur,  if  they  become 
pregnant  again,  or  is  it  safe  for  them  to  become  i)regnant  again.  Before 
answering  this  question  it  is  well  to  bear  in  mind  the  fact  that  so  long  as 
there  is  any  trace  of  the  trouble  in  the  urine  there  is  very  apt  to  be  an 
exacerbation  of  it  if  the  patient  becomes  pregnant. 


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Fig.  375. — Puerperal  chart.     Mrs.  L.    Pyelitis  of  remaining  kidney. 

It  has  been  known  to  recur  in  three  successive  pregnancies,  as  reported 
by  Vinay  anrl  mentioned  above.  On  the  other  hand,  if  the  urine  has 
been  free  from  all  evidence  of  pyelitis  for  a  year  or  more,  the  author 
believes  the  chances  of  a  recurrence  in  a  subsequent  pregnancy  are  small. 
The  only  1  of  his  23  cases  known  to  have  become  pregnant  again  passed 
through  her  second  pregnancy,  labor  and  the  puerperium  without  any 
trouble  in  the  urinary  tract. 

In  conclusion,  I  would  state  that  patients  who  have  had  a  pyelitis  com- 
plicating pregnancy  or  the  puerperium  should  be  strongly  advised  not 
to  become  pregnant  again  until  all  traces  of  the  disease  have  disappeared. 
In  one  of  the  author's  cases  this  required  nearly  a  year. 


PART  IV. 
PATHOLOGICAL  LABOR. 


CHAPTER  XIX. 
ABN0R:\IAL  labor  from  anomalies  IX  FORCES. 

In  normal  labor  the  active  forces  of  expulsion  and  the  passive  forces 
of  resistance  are  so  nicely  balanced  as  to  insure  a  gradual  dilatation  of 
the  parturient  canal,  a  moderate  molding  of  the  presenting  part  and 
an  intermittent   but    progressive    ad- 
vance of  the  fetus  without  injury  to 
mother   or    child.     This   balance    be- 
tween expulsive  and  resistant  forces, 
however,  is  easily  disturbed,  and  this 
disturbance  may  arise  from  a  relative 
deficiency     or    excess    in    either    the 
power    of   expulsion    or  the  force  of 
resistance. 

The  expulsive  forces  consist  of  the 
muscular  power  of  the  uterine  body 
and  of  the  abdominal  wall.  The 
resistant  forces  comprise  the  bony 
pelvis  (hard  parts),  and  the  cervix, 
vagina  and  pelvic  floor  (soft  parts). 
This  may  be  illustrated  by  the  accom- 
panying Fig.  376,  in  which  the  expul- 
sive forces  are  represented  above  the 
line    A-B    and    the    resistant    forces 

below.  Even  if  both  the  expulsive  forces  and  the  resistant  forces  are 
normal,  the  fetus  from  its  size,  attitude,  presentation  or  position  may 
disturb  the  normal  process  of  the  labor  and  thus  cause  dystocia. 

Abnormal  labor  then  may  arise  from: 

A.  Anomalies  in  the  forces. 

B.  Anomalies  in  the  passages. 

C.  Anomalies  in  the  fetus. 

Ahnorvial  labor  from  anomalies  in  the  forces  concerns  both  the  forces 
of  expulsion  and  resistance,  either  of  which  may  be  deficient  or  relatively 
in  excess. 

39  (609) 


Fig.  376. — Diagram   illustrating  expul- 
sive and  resistant  forces. 


GIO  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

DEFICIENCY  IN   THE   EXPULSIVE   FORCES. 

As  the  expulsive  forces  comprise  the  contractions  both  of  the  uterus 
and  the  abdominal  wall  they  will  be  studied  separately. 

Uterine  Inertia. — Instead  of  normal  uterine  contractions  recurring  at 
gradually  shortening  intervals  and  with  increasing  force,  and  causing  a 
progressive  dilatation  of  the  cervix  with  advance  of  the  presenting  part, 
the  contractions— "pains" — may  become  less  and  less  frequent  and  less 
and  less  efficient,  although  perhaps  distressing  and  the  labor  be  unduly 
prolonged.  This  prolonged,  inefficient  labor  due  to  lack  of  power  in  the 
uterine  contractions  is  called  uterine  inertia.  This  uterine  inertia  may 
be  caused  by  the  condition  of  the  muscle  itself,  without  obstruction  to 
the  birth  of  the  child,  and  is  then  called  primary  inertia,  or  it  may  be 
due  to  exhaustion  caused  by  an  excessive  amount  of  work  thrown  upon 
the  uterus  by  more  or  less  obstruction  in  the  parturient  canal.  It  is  then 
called  secondary  inertia.  It  should  be  stated  in  this  connection,  however, 
that  there  are  certain  border-line  cases  which  are  difficult  to  classify  as 
either  primary  or  secondary  inertia  and  partake  of  the  characters  of 
each.  Thus  the  resistance  presented  by  a  rigid  cervix  may  be  sufficient 
to  exhaust  the  uterine  contractions  of  one  uterus,  while  its  dilatation 
would  be  an  easy  task  for  another. 

Primary  Uterine  Inertia.^ — Primary  uterine  inertia  may  be  due  to  various 
causes,  as  for  instance: 

(a)  Defective  development  of  the  uterine  muscle.  This  being  but  a 
local  manifestation  of  defective  muscular  development  throughout  the 
body. 

(6)  Overdistention  of  the  uterine  muscle,  as  from  multiple  pregnancy, 
hydramnios,  etc. 

(c)  Congenital  malformation  of  the  uterus  interfering  with  normal 
contractions. 

{d)  Distortion  of  the  uterine  muscle  by  fibroid  growths. 

{e)  Weakening  of  the  uterine  muscle  b}'  disease. 

(/)  Defecti^"e  innervation  of  the  uterine  muscle. 

These  different  factors  deserve  separate  consideration  as  they  are  far 
from  having  an  equal  influence. 

Although  undoubtedly  defective  muscular  development  affects  the 
power  of  uterine  contraction,  it  is  often  found  that  the  lessened  muscular 
resistance  in  the  pelvic  floor  so  nearly  offsets  the  lessened  uterine  tone 
that  the  labor  progresses  normally. 

So  often  has  the  author  seen  delicate  "hot-house"  looking  young  women 
with  scarcely  anj'  muscular  development  pass  through  an  easy,  normal 
labor,  that  he  has  learned  to  look  forward  to  their  labor  with  much  less 
anxiety  than  in  the  case  of  certain  robust,  athletic  women  whose  uterine 
muscle  is  undoubtedly  of  excellent  tone,  but  whose  pelvic  floor  is  as  rigid 
as  their  legs  or  arms. 

That  overdistention  of  the  uterus  interferes  with  its  tone  and  tendency 
to  contract  both  during  and  after  labor  is  a  fact  familiar  to  every  obstet- 
rician and  can  easily-  be  understood  by  students. 


DEFICIENCY  IN   THE  EXPULSIVE  FORCES  611 

From  the  author's  experience  he  can  recall  a  number  of  instances  in 
which  the  congenital  malformation  of  the  uterus  or  the  presence  of  fibroid 
tumors  in  the  uterine  wall  have  been  associated  with  long,  tedious  labors, 
followed  by  relaxation  of  the  uterus  and  postpartum  hemorrhage. 

The  weakening  of  the  uterine  muscle  by  disease  does  not  often  appear 
as  a  factor  in  uterine  inertia,  although  it  is  usually  included  among 
the  causes  of  this  condition.  Patients  are  often  seen  pass  through  normal 
labor,  although  emaciated  by  prolonged  phthisis  or  typhoid  fever,  and 
this  is  probably  explained  as  above  that  the  muscular  resistance  of  the 
pelvic  floor  is  lessened  at  the  same  time  as  the  expulsive  power  of  the 
uterine  muscle. 

The  question  of  defective  innervation  of  the  uterine  muscle  causing 
uterine  inertia  is  an  interesting  one,  although  difficult  to  prove.  Certain 
it  is  that  outside  influences  like  the  arrival  of  the  physician,  or  some 
unexpected  news,  will  often  inhibit  uterine  contractions  for  a  time. 
Furthermore,  the  intensity  of  the  pain  in  women,  unaccustomed  to  suffer- 
ing, and  nervously  unable  to  bear  it,  will  often  seem  to  send  an  inhibitory 
influence  to  the  centre,  presiding  over  uterine  contractions,  lessening 
their  force  or  prolonging  the  interval  between  them.  For  these  reasons 
it  is  the  nervous,  hysterical  woman  with  poor  nerve  control,  in  whose 
confinement  uterine  inertia  should  be  anticipated.  In  this  connection 
attention  may  well  be  called  to  the  fact  that  if  the  bladder  is  distended, 
the  pressure  upon  it  during  a  uterine  contraction  may  cause  such  acute 
pain  as  to  inhibit  normal  uterine  action. 

The  clinical  picture  of  primary  uterine  inertia  is  familiar  to  every 
obstetrician.  The  uterine  contractions,  although  perhaps  starting  with 
the  normal  intervals,  do  not  continue  as  they  should,  but,  instead  of 
recurring  with  increased  frequency  and  force,  perhaps  grow  less  and 
less  frequent  and  gradually  diminish  in  effectiveness.  An  examination 
of  the  cervix  at  this  time  will  often  show  but  little  dilatation  in  spite  of 
the  fact  that  the  woman  has  been  in  labor  for  hours  and  her  pains  have 
been  more  and  more  distressing.  She  is  just  the  one  to  think  that  she 
has  had  a  terrible  experience  by  the  time  the  first  stage  is  half  completed. 
It  is  only  fair  to  state  in  this  connection,  however,  that  the  ability  to 
endure  pain  varies  greatly  in  different  women  and  depends  very  largely 
upon  the  nervous  organization  of  the  individual.  It  is  not  unusual  to 
meet  with  the  type  of  calm,  phlegmatic  women,  who  think  a  little  pain 
is  nothing  and  who  pass  through  the  discomfort  of  the  first  stage  with 
hardly  a  murmur,  but  at  the  present  day,  with  our  high-tension  mode 
of  life  and  with  women  whose  nervous  systems  are  at  equally  high  ten- 
sion, it  is  more  their  misfortune  than  their  fault  that  the  nagging,  ineffec- 
tive pains  of  the  first  stage  seem  more  than  they  can  stand. 

Secondary  Inertia.- — The  conditions  present  in  secondary  uterine  inertia 
are  different:  The  contractions  began  normally  and  continued  with 
increasing  force  and  frequency  until  the  uterine  muscle  became  tired  out. 
This  is  what  might  be  expected  of  any  muscle  of  which  the  work  demanded 
is  more  than  it  is  equal  to.  The  uterus  is  tired  and  the  woman  herself 
is  tired,  both  nervously  and  physically.    This  fatigue  of  the  uterus  may 


612  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

come  early  or  late,  depending  upon  the  endurance  of  the  uterus  and  the 
amount  of  work  to  be  done.  The  endurance  of  the  uterus,  like  that  of 
the  woman  herself,  seems  to  depend  both  on  the  muscle  tone  and  general 
nerve  control.  The  amount  of  work  demanded  may  be  greater  than 
normal  on  account  of  some  slight  obstruction  in  the  canal,  perhaps  due 
to  excessive  rigidity  of  the  cervix,  or  to  absence  of  the  aid  of  the  fluid 
wedge,  caused  by  early  rupture  of  the  membranes;  it  may  be  due  to  an 
abnormal  presentation,  or  position  of  the  child,  or  the  presence  of  a 
tumor,  or  lastly,  it  may  be  due  to  an  impassable  contraction  of  the  pelvis. 

The  result  of  both  primary  and  secondary  uterine  inertia  is  prolonged 
labor,  and  this  prolongation  varies  greatly  in  importance  according  to 
whether  the  membranes  are  ruptured  or  not  and  whether  the  patient  is 
in  the  first  or  second  stage.  If  the  membranes  are  unruptured  and  the 
woman  is  in  good  general  condition  the  first  stage  of  la])or  may  often  be 
prolonged  for  hours,  perhaps  even  davs,  without  danger  to  mother  or 
child. 

On  the  other  hand,  if  the  membranes  are  ruptured,  the  author's 
experience  teaches  that  the  prolongation  of  the  labor  beyond  forty-eight 
hours  is  associated  with  danger  alike  to  the  child  and  the  mother.  To 
the  child  from  interference  with  its  placental  circulation;  to  the  mother 
from  increased  risk  of  infection.  For  this  reason  it  is  his  custom  at  the 
Sloane  Hospital  not  to  allow  a  woman  to  go  more  than  twenty-four  hours 
with  ruptured  membranes  before  efforts  are  made  to  excite  uterine 
contractions. 

Although,  as  stated  above,  prolongation  of  labor  in  the  first  stage  may 
be  safely  allowed  to  continue  for  many  hours  if  the  membranes  are 
unruptured,  and  even  with  ruptured  membranes  may  continue  twenty- 
four  to  forty-eight  hours  without  causing  anxiety,  when  the  labor  enters 
the  second  stage  there  should  be  constant  progress,  and  in  the  author's 
practice  the  interruption  of  progress  in  the  second  stage  of  labor  resulting 
in  no  advance  for  from  one  to  two  hours  is  considered  an  indication  for 
interference. 

Treatment.- — Prophylaxis. — On  considering  the  etiology  of  uterine 
inertia  it  is  easy  to  see  the  importance  of  having  the  woman  approach 
her  labor  in  the  best  possible  condition  of  body  and  nervous  system. 
Hence  the  reasons  for  advising  during  pregnancy  regular  (not  violent) 
exercise,  plenty  of  fresh  air,  long  hours  of  sleep,  and  freedom  from 
sources  of  nerve  irritation  as  far  as  possible.  If  unable  to  take  active 
exercise  during  the  latter  part  of  pregnancy,  passive  exercise  in  the 
shape  of  massage  will  often  do  much  toward  keeping  the  woman  in  good 
general  condition.  If  there  is  a  history  of  previous  uterine  inertia  or  if 
for  any  reason  this  is  anticipated,  the  administration  of  strychnin 
sulphate,  gr.  3^77,  three  times  a  day  for  three  or  four  weeks  previous  to 
the  labor  will  often  prove  serviceable.  If  the  woman  is  anemic,  some 
preparation  of  iron  is  indicated. 

During  Labor. — In  the  treatment  of  all  forms  of  uterine  inertia  one  of 
the  first  essentials  is  an  accurate  diagnosis  of  the  conditions  present.  Are 
the  presentation  and  position  normal?  Is  the  relative  size  of  child  and  par- 


DEFICIENCY  IN   THE  EXPULSIVE  FORCES  613 

turient  canal  such  that  dehvery  j^er  vias  naturales  is  possible?  Too  often 
there  are  seen  in  consultation  cases  which  have  had  feeble,  ineffectual 
pains  most  of  the  day  or  most  of  the  night,  and  in  which  a  careful  exami- 
nation reveals  an  occipitoposterior  position  in  which  a  manual  rotation 
of  the  head  and  a  proper  application  of  the  forceps  would  have  termi- 
nated the  labor  hours  before,  with  markedly  less  suffering  to  the  mother 
and  greater  safety  to  the  child.  It  is  certainly  time  to  recognize  the  fact 
that  posterior  positions  of  the  occiput  are  often  associated  with  feeble, 
ineffectual  uterine  contractions.  The  diagnosis  in  this  condition  can 
often  be  suspected  at  least  from  the  description  of  the  case:  "many  hours 
of  labor  with  ineffectual  pains  and  no  advance."  Again,  too  often  there 
are  seen  neglected  cases  of  uterine  inertia  in  which  the  relation  between 
the  child  and  the  parturient  canal  is  such  as  to  render  delivery  through 
the  natural  passages  impossible,  and  yet  the  uterus  has  been  allowed  to 
work  away  for  hours  at  this  impossible  problem  until  the  organ  itself 
has  become  exhausted,  the  child's  life  endangered  and  the  operation 
of  Cesarean  section  which  hours  before  would  have  easily  saved  the 
child  with  little  risk  to  the  mother,  now  has  associated  with  it  a  relatively 
high  mortality.  ^Yith  an  accurate  diagnosis  made  of  the  conditions 
present,  and  with  abnormalities  in  position  and  size  excluded,  the  question 
may  well  be  asked :  Does  the  patient  need  reassurance,  rest  or  stimulating 
drugs  ? 

If  the  inertia  is  of  the  primary  variety  and  largely  dependent  upon 
the  nervous  apprehension  of  the  woman,  much  can  often  be  accomplished 
by  the  moral  support  of  the  obstetrician  in  assuring  her  that  everything 
is  all  right  and  in  urging  her  to  endure  the  pains  as  bravely  as  she  can. 
If  the  inertia  seems  to  be  due  to  the  fact  that  the  acuteness  of  the 
pain  acts  as  an  inhibitory  impulse,  preventing  normal  uterine  contrac- 
tions, the  administration  of  morphin  sulphate,  gr.  \,  hypodermically,  or 
chloral  hydrate,  gr.  xx-xxx,  in  warm  water  or  milk  per  rectum  will  often 
remove  the  inhibition  and  after  a  little  rest  greatly  improve  the  uterine 
contractions.  If  the  inhibitory  impulse  comes  from  a  distended  bladder, 
increasing  the  distress  of  each  uterine  contraction,  the  bladder  should  be 
emptied. 

When  the  inertia  is  distinctly  secondary  and  due  to  exhaustion,  unless 
the  obstacle  to  the  advance  of  the  presenting  part  is  unsurmountable, 
the  indication  is  certainly  rest.  A  woman  is  often  seen  tired  out,  nervous 
and  discouraged,  feeling  that  she  has  done  all  she  can,  yet  has  accom- 
plished little;  and  that  the  end  is  far  off.  If  this  woman  is  reassured,  is 
told  that  she  is  only  tired  and  needs  rest  and  is  then  given  morphin  or 
chloral  as  indicated  above,  is  allowed  to  secure  a  little  rest  and  is  then 
given  some  easily  digested  nourishment  like  hot  broth,  the  whole  picture 
often  changes.  She  will  usually  resume  her  labor  with  new  courage, 
the  pains  will  be  stronger  and  the  labor  will  progress  normally  to  its 
termination. 

Where  intrapartum  stimulation  of  uterine  contractions  by  the  use  of 
drugs  is  indicated,  three  drugs  should  be  considered:  strychnin,  quinine, 
and  pituitary  extract.    The  use  of  ergot,  formerly  in  vogue  for  uterine 


614  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

inertia  should  l)e  absolutely  abandoned  until  after  the  child  is  born  and 
the  placenta  expelled .  The  contractions  of  the  uterus  produced  by  ergot 
are  tonic  in  character  and  both  interfere  with  the  normal  progress  of 
labor  and  endanger  the  life  of  the  child.  The  employment  of  strychnin 
and  quinine  during  labor  for  stimulatuig  uterine  contractions  is  often 
serviceable  and  usually  safe.  The  contractions  under  the  use  of  these 
drugs  are  intermittent,  resembling  those  of  normal  labor,  and  do  not 
endanger  the  child.  The  method  usually  followed  by  the  author  is  to 
give  strych.  sulph.,  gr.  ^q,  and  quinine  sulph.,  gr.  v,  every  four  hours  alter- 
nately. In  patients  especially  susceptible  to  quinine,  disagreeable  symp- 
toms, such  as  ringing  in  the  ears,  etc.,  may  be  produced  early  and  the 
discomfort  of  her  labor  be  increased  by  the  drug.  In  these  cases  it  should 
be  discontinued  at  once. 

Fituitary  Extract. — Since  1909  the  use  of  pituitary  extract  obtained 
from  the  posterior  lobe  of  the  gland  has  become  quite  extensive  for  the 
relief  of  both  primary  and  secondary  inertia,  and  experience  with  it  has 
now  been  sufficiently  large  to  demonstrate  both  its  value  and  its  dangers, 
and  to  indicate  the  conditions  under  which  its  employment  is  likely  to 
be  followed  by  success  and  under  wdiich  by  failure.  The  drug  is  best  put 
up  in  ampoules,  each  containing  1  c.c.  representing  0.1  grain  of  the  fresh 
posterior  lobe  of  the  pituitary  body.  It  should  be  administered  intra- 
muscularly, preferably  in  the  gluteal  region  under  strict  aseptic  precau- 
tions. Its  effect  is  usually  evident  in  about  five  minutes  and  lasts  about 
twenty  minutes.  The  dose  of  1  c.c.  may  be  given  twice  or  three  times 
at  intervals  of  half  an  hour.  While  admitting  great  advantages  in  the 
use  of  the  drug  under  proper  conditions,  the  dangers  will  first  be  empha- 
sized. Under  full  doses  the  uterine  contractions  are  sometimes  so  stormy 
and  so  tonic  as  to  endanger  the  life  of  the  child  by  asphyxia  and  the  life 
of  the  mother  by  rupture  of  the  uterus,  several  instances  of  which  have 
been  reported.  Experience  with  the  drug  has  demonstrated  the  fact  that 
as  a  means  of  inducing  labor  it  is  uncertain  and  unsatisfactory;  that  for 
uterine  inertia  in  the  first  stage  of  labor  or  until  the  cervix  is  either  dilated 
or  dilatable,  pituitary  extract  is  unsafe. 

On  the  other  hand,  when  the  resistance  of  the  cervix  is  obliterated  and 
the  bony  pelvis  is  not  contracted,  the  drug  is  a  valuable  one  and  will 
often  obviate  the  need  of  delivery  by  the  forceps  or  will  change  the  type 
of  the  forceps  operation  demanded  from  the  high  operation  to  the  medium 
or  the  low.  The  author's  rule  in  the  use  of  pituitary  extract  for  uterine 
inertia  is  not  to  administer  it  unless  conditions  are  such  that  if  necessary 
he  could  artificially  deliver  the  child  within  a  few  moments  if  the  uterine 
contractions  under  the  influence  of  the  drug  became  too  stormy  and 
prolonged.  Chloroform,  as  a  rule,  will  relax  these  tonic  contractions  of 
the  uterus  and  should  always  be  at  hand.  An  intramuscular  injection 
of  pituitary  extract  at  the  beginning  of  a  Cesarean  section  is  often  of 
value  as  a  substitute  for  ergot  to  prevent  relaxation  of  the  uterus  after 
the  child  is  extracted. 

A  careful  consideration  of  uterine  inertia  demonstrates  the  fact  that 
there  are  two  main  classes  in  which  cases  may  be  grouped: 


DEFICIENCY  IN   THE  EXPULSIVE  FORCES  615 

1.  Those  cases  of  inertia  in  which  reassurance^  rest  and  the  stimulating 
drugs,  such  as  strychnin,  quinine  and  pituitary  extract,  will  accomplish 
the  desired  result. 

2.  Those  cases  which  cannot  be  relieved  by  the  above-mentioned 
methods  and  which  require  artificial  delivery. 

The  first  class  has  already  been  sufiiciently  considered.  It  now  remains 
to  consider  the  second  class  and  to  answer  the  question,  Under  what 
conditions  should  uterine  inertia  be  treated  b}^  artificial  delivery?  In 
general  this  question  may  be  answered  as  follows:  When  either  fetal 
life  or  maternal  convalescence  is  endangered. 

Fetal  Danger. — It  would  seem  that  by  this  time  the  importance  of 
carefully  noting  the  rapidit}^  and  quality  of  the  fetal  heart  sounds  during 
labor  would  be  generally  recognized,  and  this  simple  precaution  be  uni- 
formly and  frequently  observed,  yet  among  general  physicians  who 
practice  obstetrics  this  is  not  the  case. 

There  is  no  criterion  of  the  fetal  well-being  which  equals  the  character 
of  the  fetal  heart  sounds,  yet  this  criterion  is  often  neglected. 

The  need  of  frequent  observations  of  the  fetal  heart  sounds  is  in  the 
author's  judgment  one  of  the  deciding  arguments  in  favor  of  the  dorsal 
position  of  the  woman. in  labor  rather  than  the  lateral  position. 

The  lateral  position  requires  frequent  changes  to  the  dorsal  for  proper 
auscultation,  and  this  means  frequent  disarrangement  of  the  sterile 
drapery.    The  dorsal  position  needs  no  such  change. 

The  excuse  of  many  who  neglect  auscultation  of  the  fetal  heart  during 
the  second  stage  of  labor  is  that  after  they  have  put  on  their  rubber 
gloves  they  cannot  handle  the  stethoscope  without  unsterilizing  their 
gloves. 

If  the  obstetrician  has  with  a  stethoscope  carefully  auscultated  the 
fetal  heart  during  the  first  stage  of  labor,  it  is  not  necessary  for  him  to 
use  the  stethoscope  during  the  second  stage  when  his  hands  are  sterile- 
gloved.  For  many  years  the  writer  has  carefully  and  frequently  auscul- 
tated the  fetal  heart  in  the  second  stage  of  labor  by  raising  with  gloved 
hands  the  sterile  towel  usually  kept  on  the  patient's  abdomen,  and, 
having  the  nurse  pull  down  the  night-dress  so  as  to  cover  the  abdomen, 
with  ear  applied  to  the  night-dress  he  has  auscultated  as  desired;  the 
nurse  has  then  folded  back  the  night-dress,  he  has  replaced  the  sterile 
towel  which  he  has  been  holding  with  sterile  hands  and  this  process  has 
been  repeated  as  often  as  necessary. 

The  importance  of  frequent  auscultation  of  the  fetal  heart  during 
the  second  stage  of  labor  may  well  be  considered  as  great.  It  furnishes 
the  chief  criterion  of  the  well-being  or  danger  of  the  child,  and  in  uterine 
inertia  if  on  auscultation  the  fetal  heart  is  found  markedly  slowed  and 
especially  if  with  this  lessened  rate  there  is  associated  a  well-marked 
irregularity,  fetal  danger  is  established  and  artificial  delivery  is  indi- 
cated. 

This  does  not  necessarily  mean  that  forceps  delivery  or  version  must 
be  undertaken  at  once,  or  still  less  that  one  of  the  cutting  operations 
for  delivery  in  dystocia  should  be  performed.    It  simply  means  that  the 


616  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

labor  should  bo  expedited  in  the  best  way  under  the  existing  circum- 
stances. If  the  cervix  is  still  undilat(>d  and  there  is  no  dystocia  from  the 
hard  parts,  the  use  of  the  elastic  bag  until  the  labor  can  be  more  easily 
terminated  by  nature  or  the  forceps,  may  be  the  best  procedure. 

Every  obstetrician  realizes  that  with  normal  relations  in  size  between 
fetus  and  pelvis  the  key  to  the  situation  lies  in  the  dilatation  of  the  cervix. 
With  that  undilated  he  must  wait.  With  the  cervix  dilated  the  situa- 
tion is  under  his  control  and  he  can  terminate  the  labor  mechanically 
if  he  wishes.  In  the  conical  elastic  bag  of  Champetier  de  Ribes,  modi- 
fied by  Dr.  James  D.  Voorhees,  of  New  York,  and  illustrated  in  Fig.  432, 
the  obstetrician  has  an  instrument  which,  in  uterine  inertia,  whether 
primary  or  secondary,  with  membranes  intact  or  ruptured  (and  espe- 
cially in  the  latter),  serves  a  most  useful  purpose.  The  use  of  these  bags 
for  the  induction  of  premature  labor  will  be  discussed  later  (see  page  739), 
but  in  uterine  inertia  they  meet  the  indication  in  dilating  the  cervix 
before  the  internal  os  is  obliterated  better  than  anything  else  known  to 
the  author.  They  do  it  evenly,  w^ith  elastic  pressure  and  in  a  conical 
shape  resembling  closely  the  conical  fluid  wedge  of  the  bulging  bag  of 
waters  used  by  nature  in  dilating  this  canal. 

Moreover,  the  elastic  bag  not  only  has  the  dilating  power  which  would 
be  given  it  if  the  tube  attached  to  the  apex  of  the  cone  were  pulled  upon, 
but  the  presence  of  the  conical  bag  in  the  cervical  canal  causes  reflex 
muscular  contractions  of  the  uterine  body  and  thus  calls  forth  the  vis  a 
tergo  which  was  lacking.  W' ith  the  uterine  contractions  forcing  the  uterine 
contents  down  upon  the  base  of  the  bag,  aided  if  necessary  by  occasional 
traction  upon  the  tube  attached  to  its  apex,  the  internal  os  is  gradually 
dilated  and  the  cervix  retracted.  If  one  bag  is  not  sufficient  by  its 
stimulating  and  dilating  power  to  bring  about  the  continuance  of  the 
labor  to  a  successful  issue,  the  next  size  may  be  used.  The  general  rule 
being  to  use  first  the  largest  size  which  can  be  easily  introduced,  i.  e., 
No.  1,  2,  or  3,  it  being  understood  that  the  fewer  the  manipulations  of 
the  parts,  the  less  the  discomfort  to  the  woman  and  the  less  risk  of 
infection. 

It  is  seldom  wise  in  a  vertex  case  to  use  bag  No.  4,  as  there  is  danger 
of  displacing  the  presenting  part  and  allowing  prolapse  of  the  cord. 

If  the  internal  os  has  disappeared  it  is  almost  impossible  to  place  the 
elastic  bag  in  the  cervix  without  displacing  the  presenting  part,  but 
under  slight  anesthesia  the  cervical  ring  may  be  dilated  by  introducing 
and  separating  two  or  more  fingers  or  two  fingers  and  the  thumb  of  one 
hand  (Harris)  or  one  or  two  fingers  of  each  hand  (Edgar). 

With  this  accomplished  the  labor  which  previously  had  reached  a 
stand-still  is  often  seen  to  progress  steadily  to  a  successful  termination. 

Even  with  internal  os  obliterated,  manual  dilatation  must  be  performed 
gradually  and  with  care,  for  the  tissue  of  the  cervix  varies  greatly  in 
elasticity  in  different  cases  and  the  author  reraem})ers  seeing  in  consulta- 
tion a  case  in  which  this  dilatation  produced  a  laceration  of  the  cervix 
causing  so  severe  an  intrapartum  hemorrhage  as  nearly  to  exsanguinate 
the  patient.    Careful,  gradual,  manual  dilatation  of  the  cervix,  however, 


DEFICIENCY  IN   THE  EXPULSIVE  FORCES  617 

in  cases  of  uterine  inertia  with  internal  os  obliterated,  is  a  procedure  of 
extreme  value. 

If  the  examination  discloses  the  fact  that  a  posterior  position  of  the 
occiput  is  the  cause  of  the  delay  and  the  embarrassment  of  the  fetal 
circulation,  artificial  rotation  and  delivery  are  indicated. 

In  the  presence  of  a  slow,  irregular  fetal  heart,  a  dystocia  of  the  hard 
parts,  too  great  to  be  dealt  with  by  forceps  or  version,  indicates  a 
Cesarean  section,  unless  this  operation  is  contra-indicated  by  the  feeble 
condition  of  the  fetal  heart  or  the  too-long  delayed  decision  to  deliver 
artificially  and  the  great  probability  that  the  woman  is  already  infected. 

Uterine  inertia  associated  with  fetal  heart  sounds  indicating  danger  to 
fetal  life  is  one  of  the  first  types  of  inertia  indicating  artificial  delivery. 

Uterine  Inertia  Endangering  Maternal  Convalescence. — If  the  membranes 
have  ruptured,  prolonged  pressure  of  the  child  against  the  uterine  wall 
or  against  the  vagina  or  bladder,  even  if  the  pressure  is  not  accompanied 
by  uterine  contractions  powerful  enough  to  accomplish  any  advance 
of  the  presenting  part,  may  endanger  maternal  convalescence  by  post- 
partum hemorrhage,  by  infection,  by  necrosis,  or  by  an  increased 
mortality  of  any  operation  resorted  to  for  delivery. 

In  a  certain  class  of  women,  with  nervous  system  of  unstable  eciuili- 
brium,  the  nerve  and  muscle  tone  seem  only  equal  to  the  task  of  dilating 
the  cervix,  perhaps  not  that.  The  immediate  result  is  an  exhausted 
woman,  perhaps  an  hysterical  woman,  with  labor  only  partly  completed. 
If  these  patients  are  allowed  to  continue  in  their  ineftective  labor,  the 
remote  result  may  be  a  nervous  and  physical  ^^Teck  for  a  year  or  two 
after  the  birth  of  the  child.  In  a  certain  number  of  these  cases,  simple 
measures  such  as  rest,  reassurance,  food,  strychnin  or  quinine  may 
overcome  the  difficulty,  but  in  a  larger  number  these  measures  fail. 

This  class  and  this  condition  usually  indicates  artificial  delivery, 
usually  by  forceps,  occasionally  by  version. 

*  This  class  has  in  recent  months,  through  tlie  use  of  pituitary  extract, 
been  somewhat  reduced  in  the  number  of  those  needing  artificial  delivery, 
but  there  still  remain  a  large  number  who  should  not  be  allowed  to  con- 
tinue longer  in  labor  for  the  two  reasons  already  suggested: 

1.  The  effect  upon  the  maternal  soft  parts. 

2.  The  effect  upon  the  nervous  system. 

It  would  be  extremely  valuable  if  one  could  definitely  outline  the 
exact  condition  of  the  maternal  soft  parts  which  should  always  be  taken 
as  the  indication  for  artificial  assistance  to  nature's  eft'orts  at  delivery, 
but  this  is  almost  impossible,  as  each  case  has  to  be  studied  by  itself. 
In  general,  the  dryness  and  beginning  edema  of  the  cervix  and  vagina 
may  be  taken  as  an  indication  that  the  circulation  and  nutrition  of  the 
soft  parts  are  being  interfered  with,  and  if,  with  membranes  ruptured 
and  labor  well  under  way,  no  progress  has  been  made  for  an  hour  in 
either  dilatation  or  advance  of  the  presenting  part,  and  the  simple 
measures  of  rest,  food,  and  stimulating  drugs  have  proved  unavailing, 
artificial  mechanical  assistance  is  indicated. 

The  exact  type  of  mechanical  assistance  to  be  chosen  depends,  as 


filS  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

already  suggested,  upon  the  diagnosis  of  the  conditions  present.  If  the 
(lehiy  is  caused  l)>"  too  great  resistance  in  the  bony  canal  and  a  disprojjor- 
tion  between  it  and  the  fetal  head,  it  is  time  for  Cesarean  section  rather 
than  later  after  frequent  manipulations  have  increased  the  danger  of  the 
operation.  If  the  inertia  is  due  to  too  great  resistance  in  the  cervix,  it 
is  time  to  make  use  of  the  \aluable  assistance  of  the  elastic  bag  both  in 
dilating  the  cervix  and  stimulating  the  contractions  of  the  fundus. 

If  the  presenting  part  has  descended  to  the  pehic  floor  and  the  resis- 
tance here  has  proved  too  great  for  the  overworked  uterus  to  overcome, 
it  is  time  for  the  use  of  the  forceps  before  the  maternal  soft  parts  and  the 
fetal  brain  receive  an  undue  amount  of  pressure. 

While  discussing,  as  an  indication  for  artificial  delivery,  the  effect 
of  uterine  inertia  upon  the  nervous  system  of  the  mother  in  convales- 
cence, it  must  not  be  thought  that  this  indication  is  often  found  separate 
from  the  two  already  studied,  i.  e.,  fetal  danger  and  danger  to  the  maternal 
soft  parts.  In  fact  two,  if  not  three,  of  these  indications  are  usually  found 
associated.  The  nervously  exhausted  woman,  perhaps  hysterical  in 
labor  and  neurasthenic  for  months  afterward;  the  tired  uterus  which 
tends  to  relax,  bleed  and  become  infected  after  labor;  and  the  fetal  heart 
slowed  and  irregular  from  undue  pressure,  these  three  conditions  are  so 
often  found  combined  as  to  present  a  familiar  picture  to  e\'ery  consulting 
obstetrician.  The  author's  plea  is  for  studied,  skilled,  artificial  assistance 
in  delivery  before  the  mother  and  child  are  exposed  to  these  dangers. 

There  is  one  condition  not  usually  classed  as  uterine  inertia  to  which 
the  writer  would  like  to  call  attention.  It  is  the  long  delay  which  some- 
times intervenes  between  rupture  of  the  membranes  and  the  uterine 
contractions  of  the  first  stage  of  labor. 

Patients  sometimes  present  themselves  at  the  hospital  with  the  history 
that  their  membranes  ruptured  three,  four,  or  even  five  days  before  their 
labor  ])ains  began.  An  nnfortiuiate  experience  several  years  ago  in  which 
the  fetal  heart  ceased  before  the  labor  was  completed,  and  a  study  of  the 
temperature  charts  of  a  number  of  these  cases,  convinced  the  author 
that  in  many  particulars  they  resemble  cases  of  uterine  inertia  during 
actual  labor;  that  there  is  fetal  danger  from  interference  wuth  fetal 
circulation  from  prolonged  pressure,  and  that  maternal  morbidity  is 
common  from  sapremia  if  not  from  bacteremia. 

For  these  reasons. the  writer  has  made  it  a  rule  in  recent  years,  both  at 
the  Sloane  Hospital  and  in  his  private  practice,  to  introduce  an  elastic 
bag  (Voorhees)  into  the  cervix  if  uterine  contractions  have  not  started 
at  the  end  of  twenty-four  hours  from  the  time  of  the  rupture  of  the 
membranes. 

The  elastic  bag,  as  a  rule,  not  only  brings  on  uterine  contractions,  but 
lessens  the  further  escape  of  the  liquor  amnii,  and  the  results,  both  fetal 
and  maternal,  have  seemed  to  justify  the  procedure. 

Before  leaving  the  treatment  of  uterine  inertia,  attention  should  be 
be  called  to  the  fact  that  friction  and  manipulation  of  the  fundus  of  the 
uterus  through  the  abdominal  wall  will  often  arouse  uterine  contraction 
and  keep  the  uterus  at  its  work  as  will  nothing  else. 


DEFICIENCY  IN  THE  EXPULSIVE  FORCES  619 

Abdominal  Wall  Inertia. — ^While  in  the  first  stage  of  labor  it  is  uterine 
inertia,  or  deficiency  in  the  expulsive  force  of  the  uterus,  which  has  most 
to  do  with  prolonged  labor,  in  the  second  stage,  in  the  absence  of 
mechanical  obstacles  to  delivery,  it  is  often  a  deficiency  in  the  expulsive 
force  of  the  abdominal  muscles,  or  abdominal  wall  inertia,  which  is  at 
fault. 

Etiology.- — The  causes  of  inertia  of  the  abdominal  muscles  are  various; 
most  often  it  is  due  to  overdistention  in  previous  pregnancies  or  it  may 
be  due  to  exceptional  conditions  in  the  present  pregnancy,  as  twins, 
hydramnios,  etc.  It  may  be  but  a  part  of  a  poor  general  muscular  devel- 
opment and  here  wasting  diseases  such  as  tuberculosis  and  typhoid 
exert  a  marked  influence. 

Abdominal  wall  inertia  may  be  largely  the  result  of  inhibiting  impulses, 
started  by  the  acuteness  of  the  pains.  Thus,  certain  women  in  whom 
the  sense  of  pain  is  very  acute  will  cry  out  with  each  pain  and  make 
no  attempt  to  use  their  abdominal  muscles,  in  fact  seem  to  check  the 
tendency  of  the  abdominal  wall  to  contract.  This  action  is  best  seen 
by  dulling  the  acuteness  of  the  pain  with  a  little  anesthesia  when 
involuntarily  the  patient  will  bring  her  abdominal  muscles  into  action 
and  greatly  facilitate  the  progress  of  the  labor. 

Another  cause  of  inertia  of  the  abdominal  wall  is  ignorance  on  the 
part  of  the  patient,  especially  a  primigravida.  If  she  is  told  at  the 
outset  of  each  pain,  to  hold  her  breath  and  strain  downward  as  though 
having  a  constipated  movement  of  the  bowels,  she  soon  learns  to  use  her 
abdominal  muscles  to  the  best  advantage  and  the  improvement  in  the 
progress  of  the  labor  is  often  remarkable. 

There  is  one  cause  of  inertia  which  is  both  abdominal  and  uterine, 
viz.,  that  due  to  pendulous  abdomen.  The  condition,  as  will  be  shown 
later  (see  page  620),  is  usually  caused  by  a  laxity  and  stretching  of  the 
abdominal  wall,  and  as  a  rule,  is  present  only  in  multigravidse.  The  uterus 
falls  forward  as  the  pregnancy  advances;  the  abdominal  wall  has  little 
tone  and  the  resultant  of  the  uterine  and  abdominal  wall  contraction  is 
upward  and  backward  (see  Fig.  377,  arrow  A)  rather  than  downward 
in  the  normal  direction  of  the  parturient  canal  (arrow  B).  The  uterine 
muscle  soon  tires  in  action  and  uterine  inertia  is  added  to  inertia  of  the 
abdominal  wall  which  might  be  said  to  be  present  throughout  the 
pregnancy. 

Treatment. — Naturally  this  depends  largely  upon  the  cause  in  the 
individual  case.  If  after  confinement  the  abdominal  wall  of  a  patient 
is  found  markedly  relaxed  with  recti  separated,  marked  benefit  is  derived 
from  a  combination  of  exercise  and  support. 

The  practise  night  and  morning,  when  wearing  only  the  night-clothes 
or  a  loose  wrapper,  of  exercises  which  bring  in  play  and  develop  the 
abdominal  muscles,  will  do  much  toward  restoring  the  tone  of  the  abdom- 
inal wall;  furthermore,  the  wearing  during  the  daytime  of  a  properly 
fitting  corset  so  adjusted  as  to  give  support  to  the  lower  part  of  the 
abdomen  and  thus  lessen  the  tendency  of  all  the  abdominal  viscera  to 
sag,  will  prove  of  marked  aid  in  the  efforts  to  restore  tone. 


620 


ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 


As  indicated  above,  if  the  abdominal  wall  inertia  is  due  to  the  inhibi- 
tory impulses  produced  by  the  acuteness  of  the  pain,  a  few  whiffs  of 
anesthetic  gi\en  with  each  i)ain  and  instruction  to  the  patient  to  press 
down  when  she  has  a  pain  will  usually  meet  the  indication. 

If  during  pregnancy  the  abdominal  wall  shows  a  tendency  to  become 
pendulous,  it  should  be  supported  by  a  proi)erly  fitting  corset  or  abdominal 

bandage  which  will  support  the  ab- 
domen and  maintain  the  uterus  in 
the  long  axis  of  the  body.  It  is  a 
mistake  to  think  that  it  is  nearer 
nature  and  therefore  better  for  a 
woman  during  pregnancy  to  go 
about  without  any  abdominal  sup- 
port. As  the  abdominal  wall  dis- 
tends, especially  in  multigravidse, 
the  uterus  becomes  more  lax  and 
the  fetus  is  less  likely  to  engage 
normally  in  the  brim  of  the  pelvis 
and  at  the  proper  time. 

If  the  case  of  pendulous  abdo- 
men is  seen  in  labor,  the  abdom- 
inal wall  and  uterus  must  be 
supported  in  the  axis  of  the 
body  either  by  an  abdominal 
bandage  which  is  often  difficult 
to  retain  in  place,  or  by  the 
obstetrician  or  nurse  keeping  up 
pressure  with  the  hands  upon 
the  abdomen  and  fundus  of  the 
uterus  while  the  patient  lies  upon 
her  back.  In  a  case  of  the  author's 
he  was  obliged  to  spend  the  whole 
day  pressing  with  his  hands  upon 
the  abdomen  of  his  patient  and 
stimulating  the  fundus  of  her 
uterus,  in  order  to  keep  the  fetus 
in  the  normal  axis  of  the  parturient 
o-,-,     -D     ,  ,        ,  ,  -iu     •         canal  and  overcome  the  tendency 

377. — Pendulous  abdomen  with  mis-  i    i        •       i  u   • 

directed  force  causing  inertia.  tO  abdomuial  Wall  mcrtia. 


Fig. 


RELATIVE   EXCESS   IN    THE   EXPULSIVE   FORCES. 

Precipitate  Labor. — Labor  in  order  to  be  normal  in  mechanism  and 
duration  presupposes  a  certain  amount  of  resistance  in  the  cervix  and 
pelvic  floor  which  requires  time  to  overcome,  during  which  process  there 
is  usually  ample  opportunity  for  the  patient,  nurse  and  obstetrician  to 
make  necessary  preparation  for  the  delivery  and  then  have  several  hours 
of  tedious  waiting.    In  rare  cases,  however,  especially  in  multigravidse, 


RELATIVE  EXCESS  IN  THE  EXPULSIVE  FORCES  621 

the  labor  is  terminated  with  very  few  pains,  with  scarcely  any  warning 
and  without  opportunity  to  secure  a  nurse  or  physician,  perhaps  without 
time  for  the  patient  to  reach  the  bed.  It  is  then  called  i^recipitate  labor. 
This  is,  as  a  rule,  brought  about  by  one  of  three  conditions: 

1.  Relatively  strong  expulsive  powers. 

2.  Relatively  weak  resistance. 

3.  Small  body  to  be  expelled. 

In  some  women  with  normal  tone  of  uterine  and  abdominal  walls 
the  power  of  expulsion  inherent  in  these  two  sources  of  power  is  very 
great  and  a  considerable  resistance  in  cervix,  vagina,  and  pelvic  floor  is 
easily  overcome. 

If  such  a  woman  with  a  large  pelvis  should  be  badly  lacerated  in 
cervix  and  pelvic  floor  and  without  having  her  lacerations  repaired 
should  again  become  pregnant  and  go  to  term,  provided  she  retained 
her  previous  tone  in  uterine  and  abdominal  walls,  her  labor  would  natu- 
rally be  greatly  shortened.  It  might  be  short  enough  to  give  no  time  for 
preparation  and  be  called  precipitate.  Moreover,  if  with  conditions 
favoring  a  rapid  labor,  such  as  strong  expulsive  powers,  large  roomy 
pelvis,  with  badly  lacerated  cervix  and  pelvic  floor,  labor  should  come 
on  prematurely  and  the  child  be  very  small,  it  is  easy  to  see  why  labor 
should  be  still  more  likely  to  be  precipitate  than  if  the  child  were  of  full 
size  at  full  term. 

In  a  justomajor  pelvis  or  a  congenital  split  pelvis  the  resistance  from 
the  bony  parts  is  practically  eliminated,  but  in  certain  women  with 
practically  normal  pelves  the  cervix  and  pelvic  floor  dilate  so  rapidly 
that  the  labor  is  completed  with  three  or  four  pains. 

In  many  of  these  cases  the  preliminary  softening  and  dilatation  of 
the  cervix  has  been  going  on  for  days  or  weeks  without  the  knowledge 
of  the  patient,  who  thought  it  only  a  continuance  of  the  discomforts 
of  pregnancy,  perhaps  confusing  it  with  the  intermittent  uterine 
contractions  of  pregnancy  (Braxton  Hicks's  sign)  which  in  some  give 
distress. 

Suddenly,  perhaps  with  rupture  of  the  membranes,  expulsive  pains 
come  on  and  the  labor  is  over. 

Prognosis. — The  danger  to  the  mother  is  usually  slight.  Lacerations 
of  the  perineum  is  the  most  common  result,  although  this  is  not  as  fre- 
quent or  extensive  as  might  be  expected.  If  the  placenta  is  firmly 
adherent,  inversion  of  the  uterus  from  traction  upon  the  cord  may  result 
and  cause  postpartum  hemorrhage,  which  may  also  come  from  premature 
detachment  of  a  placenta  not  abnormally  adherent.  Serious  syncope 
from  sudden  lessening  of  intra-abdominal  pressure,  although  possible, 
seldom  occurs. 

The  greatest  danger  is  usually  fetal,  from  the  child  falling  upon  the 
hard  floor  or  the  ground,  or  from  rupture  of  the  cord  and  hemorrhage 
therefrom,  or  from  being  deposited  in  the  basin  of  a  water-closet,  etc. 

In  other  words  the  fetal  dangers  are  those  naturally  arising  from  the 
expulsion  of  the  child  while  the  mother  is  standing  or  sitting,  rather  than 
lying  in  bed. 


G22  ABNORMAL  LABOR  FROM  ANOMALIES  IN  FORCES 

Treatment. — If  the  precipitate  labor  occurs  in  a  primigravida  it  comes 
as  a  surprise  and  there  is  no  opportunity  for  treatment,  prophyhictic 
or  otherwise.  If  such  an  experience,  however,  has  once  occurred,  much 
can  be  done  to  prevent  its  recurrence  in  a  subsequent  labor. 

The  patient,  during  the  last  weeks  of  pregnancy,  should  take  no 
violent  exercise.  She  should  ride  rather  than  walk,  shoidd  be  careful 
about  straining  at  stool,  etc.  A  nurse  should  be  in  attendance  during 
the  last  weeks  of  pregnancy  and  at  the  first  intimation  of  labor  the  patient 
should  go  to  bed  and  retain  the  horizontal  position,  preferably  on  the 
side.  She  should  be  told  not  to  bear  down  with  her  pains.  With  each 
uterine  contraction,  the  nurse,  until  the  arrival  of  the  obstetrician,  should 
administer  a  little  anesthesia  with  one  hand,  while  with  the  other  covered 
with  a  sterile  towel  she  makes  pressure  against  the  pelvic  floor. 

Irregular  Contractions  of  the  Uterus. — As  already  stated,  the  use  of 
ergot  to  stimidate  uterine  contractions  is  unsafe  while  the  fetus  is  still 
in  utero  for  the  reason  that  the  contractions,  while  often  increased  in 
force,  tend  to  become  tonic  or  tetanic,  without  the  intervening  periods 
of  relaxation  which  are  essential  to  the  maintenance  of  placental  and 
fetal  circulation;  thus  endangering  the  life  of  the  fetus  at  the  same  time 
that  it  interferes  with  the  normal  process  of  labor.  The  use  of  ergot  is 
equally  to  be  condemned  while  the  placenta  is  still  in  utero. 

When  the  author  was  a  student  it  was  the  custom  to  advise  the 
administration  of  ergot  as  soon  as  the  child  was  born  and  before  the 
expulsion  of  the  placenta.  Acting  under  this  advice,  in  his  first  obstetric 
case,  he  administered  ergot  immediately  after  the  birth  of  the  child  and 
there  followed  an  experience  never  to  be  forgotten  by  him. 

The  uterus  became  irregularly  contracted  in  the  shape  of  an  hour- 
glass, with  a  portion  of  the  placenta  included  in  the  grasp  of  the  contract- 
ing ring,  while  the  remainder  of  the  placenta  lay  above  the  ring  in  a 
relaxed  portion  of  the  uterus.  As  usually  happens  in  hour-glass  contrac- 
tions of  the  uterus,  a  profuse  hemorrhage  soon  complicated  the  situation. 

This  case  is  given  as  an  illustration  of  the  fact  that  irregular  contrac- 
tions of  the  uterus  sometimes  occur,  dividing  its  cavity  into  compart- 
ments. This  constricting  ring  is  usually  situated  at  the  junction  of  the 
upper  and  lower  uterine  segments,  i.  c,  is  the  ring  of  Bandl,  but  in  some 
cases  forms  just  below  the  foreign  body  (placenta)  which  lies  within 
the  cavity;  the  position  of  the  cavity  above  the  constricting  ring  being 
sometimes  relaxed  and  at  other  times  contracted.  It  has  been  stated 
that  an  abnormally  adherent  placenta  resulting  from  a  previous  endo- 
metritis will  sometimes  cause  a  similar  hour-glass  contraction,  but  with 
this  combination  of  cause  and  effect  the  author  has  had  no  experience. 

Treatment. — The  treatment  of  these  cases  of  irregular  or  hour-glass 
contraction  consists  in  relaxing  the  uterus  by  the  administration  of  anes- 
thesia, chloroform  or  ether,  manual  dilatation  of  the  constricting  ring, 
and  removal  of  the  placenta.  This  method  was  followed  with  success 
in  the  case  mentioned  above,  but  the  lesson  that  ergot  should  never  be 
given  in  a  case  of  labor  until  after  the  placenta  was  expelled,  was 
impressed  in  a  most  forcible  manner. 


EXCESS  IN  RESISTANT  FORCES  623 

Tetanic  Contraction  of  the  Uterus. — Occasionally  the  uterus,  espe- 
cially when  there  is  an  obstacle  to  delivery,  assumes  a  condition  of  tetanic 
contraction,  sometimes  called  tonic  spasm  of  the  uterus  or  "tonic  uterus." 
The  contractions  at  first  may  be  normal  with  intermissions  of  relaxation, 
then  as  the  obstruction  fails  to  be  overcome,  they  become  more  and  more 
vigorous  and  finally  assimie  a  condition  of  continuous  contraction,  pre- 
venting all  progress  and  exposing  the  child  to  danger  from  interference 
with  the  placental  circulation.  This  contraction  usually  involves  the 
whole  of  the  upper  uterine  segment,  as  stated  by  Veit,  although  the 
firmness  in  the  feel  of  its  lower  edge — the  ring  of  Bandl — has  caused 
certain  French  observers  (Cheron,  Budin  and  others)  to  locate  the  con- 
traction here. 

If  this  condition  of  tetanic  contraction  of  the  uterus  is  caused  by  an 
obstruction  to  the  advance  of  the  presenting  part,  the  upper  uterine 
segment  becomes  more  and  more  contracted  and  retracted,  while  the 
lower  uterine  segment  thins.  The  importance,  therefore,  of  this  tetanic 
contraction  as  leading  to  possible  rupture  of  the  uterus,  either  sponta- 
neously, or  if  a  version  is  attempted,  cannot  be  too  strongly  emphasized. 

In  the  rare  cases  where  the  uterus  assumes  this  tetanic  condition  with- 
out obstruction  to  delivery,  the  spasmodic  contraction  should  be  relaxed 
by  the  administration  of  anesthesia  and  delivery  hastened  in  the  interests 
of  both  mother  and  child.  This  same  rule  of  relaxation  by  anesthesia 
and  hastening  of  the  termination  of  the  labor  also  applies  where  there 
is  obstruction  to  the  delivery,  even  if  this  termination  of  the  labor  requires 
Cesarean  section  or  craniotomy. 

EXCESS   IS   RESISTANT   TORCES. 

Regarding  the  resistant  forces  as  composed  of  the  bony  pelvis,  the 
cervix,  the  vagina  and  the  pelvic  floor,  excess  in  their  resistance  to  the 
normal  progress  of  labor,  and  therefore  prolonged  labor,  may  be  caused 
by  abnormalities  in  any  one  of  them. 

These  may  be  studied  then  either  under  the  head  of  anomalies  of  the 
forces  or  anomalies  of  the  passages.  While  it  is  well  to  call  attention  to 
them  as  factors  in  the  forces  of  labor,  it  seems  wise  to  study  their 
abnormalities  under  the  head  of  anomalies  in  the  passages.  (See  next 
chapter.) 


CHAPTER  XX. 

ABXOiniAL  LABOR  FR0:M  ANOMALIES  IX  THE  PASSAGES. 

The  passages  concerned  in  the  mechanism  of  labor  consist  of  both 
soft  parts  and  hard  parts.  The  soft  parts  include  the  uterus,  the  vagina 
and  the  \ulva,  while  the  hard  parts  comprise  the  bony  pelvis.  The  soft 
parts  will  be  first  considered. 

ABNORMAL  LABOR  FROM  ANOMALIES   OF  THE  SOFT  PARTS   OF 

THE  PARTURIENT  CANAL.      DISPLACEMENTS  OF  THE 

UTERUS. 

Pendulous  Abdomen. — The  marked  anterior  displacement  of  the  preg- 
nant uterus  with  a  corresponding  downward  protrusion  of  the  anterior 
abdominal  wall,  called  pendulous  abdomen,  is,  as  a  rule,  caused  by  one 
of  the  three  following  conditions  and  usually  in  this  order  of  frequency: 

1 .  Lack  of  tone  in  uterine  and  abdominal  walls. 

2.  Contraction  of  the  pelvic  brim. 

3.  Shortening  of  the  abdominal  cavity  with  lumbar  lordosis. 

Lack  of  Tone  in  Uterine  and  Abdominal  Walls. — In  a  primigravida  the 
muscle  tone  of  uterus  and  abdominal  wall  usually  keeps  the  fetus  closely 
applied  to  the  peh'ic  brim  and  well  within  the  abdominal  cavity.  Hence 
it  is  that  in  her  first  pregnancy  a  woman  usualh'  discloses  her  condition 
less  than  in  her  subsequent  pregnancies.  After  several  pregnancies  have 
occurred  with  short  intervals,  the  uterine  and  abdominal  walls  become 
stretched,  lose  their  tone  and  have  less  power  to  retain  the  fetus  within 
the  normal  lines  of  the  abdomen.  This  lack  of  tone,  together  with  the 
tendency  to  an  increased  size  of  child  with  successive  pregnancies,  favors 
an  increasing  protrusion  of  the  abdomen  and  uterus  forward  and  down- 
ward, sometimes  reaching  a  position  of  30°  to  the  horizon. 

If  unaccompanied  by  abnormalities  in  spine  and  pelvis  this  variety 
of  pendulous  abdomen  is  of  little  importance  save  as  a  possible  source 
of  discomfort  during  pregnancy  and  a  cause  for  delay  in  labor. 

Treatment. — During  pregnancy  the  condition  is  most  relieved  by  sup- 
porting the  abdomen  and  uterus  by  a  well-fitting  corset  or  abdominal 
binder.  During  labor  the  force  of  uterine  contraction  in  this  condition 
is  naturally  misdirected  upward  and  backward  (as  indicated  by  arrow  A 
in  Fig.  377)  rather  than  downward  in  the  direction  indicated  by  arrow  B. 

The  malposition  of  the  uterus  sometimes  so  interferes  with  labor  that 
in  order  to  secure  and  maintain  engagement  and  descent  of  the  presenting 
part  it  is  necessary  during  most  of  the  labor  to  support  the  abdominal 
wall  and  uterus  with  an  abdominal  binder  or  the  hands  of  the  obstetrician, 
or  even  with  both. 
(624) 


ANOMALIES  OF  SOFT  PARTS  OF  PARTURIENT  CANAL       625 

Contraction  of  the  Pelvic  Brim. — ^^Yhene^'e^  there  is  present  a  marked 
condition  of  pendulous  abdomen,  especially  in  a  primigravida,  it  should 
always  be  suspected  that  there  may  be  a  contraction  of  the  pelvic  brim, 
or  at  least  a  disproportion  between  child  and  passage.  It  may  be  only 
the  result  of  an  atonic  condition  of  uterine  and  abdominal  walls,  but 
attention  has  already  been  called  to  the  fact  that  a  contracted  pelvic 
brim,  interfering  with  normal  fetal  engagement,  favors  malpresentation 
and  perhaps  pendulous  abdomen. 

Treatment. — ^The  method  of  dealing  with  the  condition  depends  upon 
the  degree  of  pelvic  deformity  and  is  considered  on  page  652.  It  is  of 
the  utmost  importance  that  the  fact  should  be  borne  in  mind  that  a  pen- 
dulous abdomen,  while  sometimes  of  minor  consequence,  may  be  asso- 
ciated with  a  condition  of  the  pelvis  needing  the  highest  skill  in  the 
delivery. 

Shortening  of  the  Abdominal  Cavity  with  Lumbar  Lordosis. — The  condition 
of  lumbar  lordosis  with  descent  of  the  thorax,  reducing  the  longitudinal 
and  anteroposterior  diameter  of  the  abdomen  will  be  considered  under 
deformity  of  the  pelvis  associated  with  disease  of  the  spinal  column 
(see  page  678). 

As  pregnancy  advances  in  this  condition,  finding  insufficient  room 
within  the  normal  confines  of  the  abdomen  the  uterus  of  necessity  enlarges 
forward  and  produces  perhaps  a  marked  condition  of  pendulous  abdomen. 
Here  then  is  a  serious  pathological  condition  of  spine  and  pelvis  associated 
with  a  protruding  and  pendulous  abdomen,  the  abdominal  shape  being 
the  clinical  picture  which  should  arouse  the  suspicion  of  the  obstetrician 
as  to  the  possible  malformation  of  the  parturient  canal.  The  treatment 
of  course  depends  upon  the  degree  of  this  malformation. 

Malformations  of  the  Uterus. — ^The  different  varieties  of  malforma- 
tion of  the  uterus  aft'ect  pregnancy  and  labor  in  dift'erent  ways.  Thus 
the  most  common  cause  of  sterility  or  delayed  pregnane}'  is  the  undevel- 
oped uterus,  for  the  treatment  of  which  artificial  dilatation  and  general 
upbuilding  offers  the  greatest  hope  of  cure.  The  variety  of  uterine  mal- 
formation most  likely  to  give  rise  to  confusion  of  diagnosis  during  preg- 
nancy and  dystocia  during  labor  is  some  form  of  double  uterus  varying 
from  the  uterus  bicornis  to  the  uterus  didelphys. 

The  possible  difficulty  in  diagnosis  during  pregnancy  is  illustrated  by 
a  case  of  the  author's,  in  which,  with  a  uterus  bicornis,  the  child  rested 
in  one  horn  and  the  placenta  was  attached  in  the  other.  On  abdominal 
examination  three  possibilities  presented  themselves: 

1.  Pregnancy  associated  with  a  soft  fibroid. 

2.  Pregnancy  associated  with  an  adherent  ovarian  cyst. 

3.  Pregnancy  in  a  uterus  bicornis. 

All  three  of  these  possibilities  were  considered,  but  the  author  must 
admit  that  a  positive  diagnosis  was  not  made  until  the  child  was  born. 
The  difiiculty  in  this  case  was  increased  by  the  fact  that  he  had  no  oppor- 
tunity to  examine  the  case  until  she  was  well  along  in  pregnancy. 

Another  difficulty  in  diagnosis  associated  with  malformation  of  the 
uterus  is  that  of  the  existence  of  pregnancy  in  one-half  of  a  double  uterus 
40 


626        ABNORMAL  LABOR  FROM  AN&MALIES  IN  PASSAGES 


where  tliere  are  two  cervices  as  well  as  two  uterine  bodies  and  menstrua- 
tion may  continue  for  a  time  from  the  unimpregnated  half.  Often  it  is 
necessary  to  delay  a  positiAe  diagnosis  for  a  few  months  until  more 
positive  symptoms  are  present. 

The  malformation  of  the  uterus  most  likely  to  cause  dystocia  is  a 
uterus  didelphys  or  a  duplication  approachuig  it. 

The  unimpregnated  half  enlarges  in  sympathy-  with  the  pregnant  side 
of  the  uterus  and  this  enlarged  unimpregnated  half  may  by  its  bulk  so 
obstruct  the  parturient  canal  as  to  cause  marked  dystocia.  Furthermore, 
in  attempts  to  overcome  the  dystocia,  complications  may  arise  as  occurred 
in  a  case  of  the  author's  in  which  a  separation  occurred  between  the 
pregnant  and  unimpregnated  portions  with  the  practical  result  of  a 
ruptured  uterus. 

Sacculation  of  the  Uterus. — Abnormalities  in  pregnancy  and  labor 
may  result  frt)m  immobile  displacements  of  the  uterus,  both  posterior 

and  anterior,  in  either  case  resulting,  as 
pregnancy  advances,  in  a  distention  or 
sacculation  of  the  wall  of  the  uterus 
opposite  to  that  fixed. 

Retroversion  of  the  Pregnant  Uterus. 
— A  pregnant  retroverted  uterus,  as  a 
rule,  follows  one  of  three  courses  and  in 
the  following  order  of  frequency: 

1 .  It  corrects  its  malposition  as  preg- 
nancy advances. 

2.  A  miscarriage  occurs. 

3.  The  uterus  becomes  incarcer- 
ated with  sacculation  of  the  anterior 
wall. 

A  great  many  pregnant,  retroverted 
uteri   rise    out  of  the   pelvis  as  preg- 
nancy advances,  and  although  there  is  a 
tendency  for  the  retroversion  to  recur 
during  the  puerperium,  still  no  further  complications  arise  during  the 
pregnancy  and  no  dystocia  occurs  as  a  result  of  the  retroversion. 

On  the  other  hand,  many  of  the  miscarriages  of  early  pregnancy  occur 
as  a  result  of  a  neglected  retroversion  of  the  uterus  in  which  the  fundus, 
being  more  or  less  fixed  in  the  hollow  of  the  sacrum,  does  not  easily 
rise  and  develop  to  accommodate  the  growing  ovum,  and  as  something 
has  to  yield,  the  direction  of  least  resistance  is  outward  through  the 
cervical  canal,  and  a  miscarriage  results.  For  this  reason  the  author  has 
emphasized  the  importance  of  early  examination  of  pregnant  women 
for  the  detection  and  correction,  if  present,  of  a  retroversion. 

Anterior  Sacculation.- — Another  result  of  pregnancy  in  a  retroverted 
uterus  is  incarceration  with  sacculation  of  its  anterior  wall. 

If  for  any  reason  the  pregnant,  retroverted  uterus  neither  corrects  its 
malposition  nor  aborts,  the  posterior  wall  being  fixed  in  the  pelvis  (see 
Fig.  378),  the  anterior  wall  alone  can  dilate  to  accommodate  the  growing 


Fig.  378. 


-Anterior  sacculation  of 
the  uterus. 


ANOMALIES  OF  SOFT  PARTS  OF  PARTURIENT  CANAL      627 

fetus.  This  distention  of  the  anterior  uterine  wall  is  called  sacculation, 
and  the  condition  as  a  whole  with  its  accompanying  symptoms  of  rectal 
pressure  and  vesical  retention  or  irritation  is  spoken  of  as  incarceration 
of  the  pregnant  uterus. 

Symptoms. — Usually  the  first  and  most  marked  symptom  is  difficulty 
in  urination.  This  may  amount  to  absolute  retention  with  intense  suffer- 
ing until  the  condition  is  relieved  by  the  use  of  the  catheter.  The  reten- 
tion may  be  followed  after  a  time  by  a  more  or  less  constant  dribble  of 
urine  from  the  overdistended  bladder.  Unless  the  condition  is  soon 
relieved  a  cystitis  develops  which  may  go  on  to  necrosis  of  the  bladder, 
perhaps  even  to  rupture  of  that  organ.  The  discomfort  of  retention  may 
be  followed  by  bloody  and  purulent  urine  with  portions  of  necrotic  mem- 
brane. If  rupture  of  the  bladder  occurs  there  are  added  the  symptoms 
of  peritonitis. 

In  the  early  stages  of  the  condition,  along  with  the  disturbances  of 
bladder  function,  may  go  symptoms  of  rectal  and  sacral  pressure,  with 
constipation,  pains  down  the  thighs,  backache,  etc.  Reflex  symptoms 
of  nausea  and  vomiting  may  also  be  present. 

Physical  Signs. — On  bimanual  examination  of  an  incarcerated,  retro- 
verted,  pregnant  uterus,  the  vaginal  fingers  detect  a  soft,  bulging 
mass  in  the  posterior  fornix  and  the  cervix  displaced  high  up  behind 
the  symphysis,  perhaps  even  above  it.  The  soft,  bulging  mass  is 
seen  to  be  continuous  with  the  cervix  and  to  be  the  hypertrophied 
posterior  uterine  wall. 

The  abdominal  hand  detects  the  fact  that  the  anterior  uterine  wall 
is  distended  and  thinned  as  compared  with  the  posterior,  and  that  by 
its  sacculation  the  growing  fetus  is  accommodated.  It  is  usually  impos- 
sible to  map  out  the  uterus  accurately  until  the  bladder  has  been  emptied. 

Diagnosis. — There  are  two  conditions  which  are  most  likely  to  be  con- 
fused with  an  incarcerated  pregnant  uterus: 

1.  A  soft  fibroid  low  down  on  the  posterior  wall  of  the  pregnant  uterus. 

2.  An  ovarian  cyst  low  down  behind  a  pregnant  uterus. 

Both  of  these  conditions  can  usually  be  diagnosed  from  an  incarcerated, 
pregnant  uterus  by  the  fact  that  in  each  the  cervix  occupies  a  more 
nearly  normal  position  in  the  vagina  rather  than  a  position  high  up  behind 
the  pubes.  Furthermore,  in  each  there  is  an  absence  of  the  intimate 
connection  between  the  bulging  mass  and  the  cervix.  In  some  instances 
a  soft  fibroid  attached  just  above  the  cervix  and  filling  the  pouch  of 
Douglas  may  present  marked  difficulties  in  diagnosis.  The  previous 
history  in  each  case  is  often  of  great  assistance. 

Treatment. — ^This  may  well  be  considered  as  (a)  prophylactic  and  (6) 
curatiw. 

Prophylactic. — While  the  majority  of  retroverted  pregnant  uteri  will 
correct  their  malposition  as  pregnancy  advances,  this  should  never 
be  taken  for  granted,  and  one  of  the  first  things  to  be  determined  in 
pregnancy  is  whether  or  not  the  uterus  is  in  normal  position  and  enlarg- 
ing normally.  If  the  uterus  is  found  retroverted  and  movable  its 
position  should  be  corrected  at  once  and  maintained  by  a  well-fitting 


628        ABNORMAL  LABOR  FROM  ANOMALIES  IX  PASSAGES 

pessary  until  the  uterus  is  large  enough  to  retain  its  position  in  front  of 
the  sacrum.  This  usually  occurs  in  the  third  or  fourth  month,  and  the 
pessary  can  then  be  removed. 

If  on  the  first  examination  the  retroverted  pregnant  uterus  appears  to 
be  fixed  in  the  pelvis,  care  should  be  taken  that  too  vigorous  manipula- 
tions do  not  induce  a  miscarriage,  but  with  the  woman  in  the  knee-chest 
position,  or  in  Sims's  position,  gentle  efforts  at  replacement  may  be  made 
by  pushing  the  posterior  uterine  wall  gently  upward  with  the  vaginal 
fingers,  perhaps  at  the  same  time  pushing  the  cervix  gently  backward. 

Sometimes  a  retroversion,  which  at  first  seemed  fixed,  can  be  corrected 
in  this  manner  at  a  single  sitting.  In  other  cases  little  is  accomplished 
at  first,  but  several  gentle  manipulations  of  this  kind  at  intervals  of 
several  days  aided  by  the  natural  gro^\i:h  of  the  pregnant  uterus  and  its 
tendency  to  correct  any  malposition,  will  often  accomplish  the  desired 
result.  As  soon  as  the  fundus  of  the  uterus  has  been  raised  to  the  neigh- 
borhood of  the  promontory  of  the  sacrum,  the  amount  gained  can  be 
maintained  by  the  use  of  a  pessary  and  the  completion  of  the  replacement 
will  often  be  found  easy  at  a  subsequent  sitting,  perhaps  even  found 
accomplished  by  nature. 

Curative. — ^Vhen  incarceration  of  the  pregnant  uterus  in  the  hollow 
of  the  sacrum  with  sacculation  of  the  anterior  uterine  wall  has  already 
occurred  and  the  accompanying  bladder  disturbances,  retention,  irrita- 
tion, etc.,  are  present,  the  situation  becomes  more  acute  and  relief  is 
imperative.  In  the  first  place  the  blaflder  must  be  emptied  by  catheter 
and  care  should  be  taken  by  the  internal  administration  of  a  urinary 
antiseptic  like  urotropin  to  avoid  the  development  of  a  cystitis.  If  a 
cystitis  has  already  developed,  in  addition  to  the  employment  of  the 
urotropin,  bladder  irrigations  may  be  of  ^■alue. 

With  the  bladder  emptied,  similar  efforts  at  replacement  by  manipula- 
tions, as  already  described,  should  be  employed,  and  after  a  few  sittings 
will  usually  succeed.  In  the  meantime  it  is  well  to  keep  the  Avoman  in 
bed,  under  close  observation,  and  with  most  careful  attention  to  the 
cleanliness  of  her  bladder  and  its  periodical  emptying. 

If  these  manipulations  fail  and  the  situation  becomes  at  all  acute, 
the  best  treatment  usually  consists  in  opening  the  abdomen  and  manually 
freeing  the  adhesions,  if  present,  and  replacing  the  malplaced  uterus  as 
recommended  by  ]Mann,^  in  1898.  Occasionally  this  condition  of  anterior 
sacculation  of  the  uterus  with  parturient  canal  obstructed  by  thickened 
posterior  uterine  Avail  is  met  Avith  at  full  term.  Here  deliAcry  is  usually 
best  accomplished  by  a  Cesarean  section. 

Posterior  Sacculation. — In  the  same  Avay  that  a  fixation  of  the  fundus 
and  posterior  wall  of  the  pregnant  uterus  in  tlie  holloAV  of  the  sacrum  and 
a  restriction  in  its  expansion  leads  to  a  sacculation  of  its  anterior  Avail, 
so  a  fixation  of  the  fundus  of  the  uterus  to  the  anterior  abdominal  Avail 
and  a  restriction  in  the  expansion  of  the  anterior  uterine  Avail  in  preg- 
nancy may  lead  to  a  sacculation  of  the  posterior  uterine  Avail.     This 

1  The  Surgical  Treatment  of  Irreducible  Retroflexion  of  the  GraA-id  Uterus,  Trans. 
Amor.  Gyn.  Soc,  1898,  xxiii,  135-140. 


ANOMALIES  OF  SOFT  PAETS  OF  PARTURIENT  CANAL      629 


anterior  fixation  of  the  uterus  is  usually  the  result  of  a  gynecological 
operation.  For  many  years  a  popular  operation  for  the  correction  of 
retroversion  of  the  uterus  was  the  fixation  of  the  fundus  uteri  to  the 
anterior  abdominal  wall  (see  Fig.  379)  and  called  ventrofixation.  It  was 
found,  however,  that  although  many  women  after  these  operations 
would  pass  through  pregnancy  and  labor  without  dystocia,  it  depended 
largely  upon  the  amount  of  stretching  in  the  adhesions  formed  between 
the  fundus  and  the  anterior  abdominal  wall.  If  these  adhesions  stretched 
so  that  they  became  simply  thin  bands  or  guys  which  allowed  normal 
expansion  of  the  uterus  in  pregnancy,  little,  if  any,  trouble  resulted.  On 
the  other  hand,  if  the  fundus  remained  firmly  fixed  to  the  anterior  abdom- 
inal wall,  only  that  portion  of  the  uterus  could  expand  to  accommodate 
the  growing  fetus  which  lay  above  and  behind  the  point  of  fixation 
(see  Fig.  379).  This  resulted  in  a 
distention  or  sacculation  of  the  pos- 
terior uterine  wall,  while  the  anterior 
wall  became  hypertrophied  and  in 
its  restricted  space  formed  a  muscu- 
lar tumor  obstructing  the  parturient 
canal  and  often  requiring  Cesarean 
section  for  the  delivery.  This 
happened  six  times  in  the  author's 
experience.  It  has  been  advised  to 
open  the  abdomen  and  free  the  adhe- 
sions and  then  leave  the  case  to  nature, 
but  the  author  believes  Cesarean 
section  a  preferable  procedure. 

Diagnosis. — The  exact  condition  is 
usually  determined  by  the  history 
of  a  previous  abdominal  operation, 
by  finding  the  cervix  displaced  far 
back,  near  and  perhaps  above  the 
promontory  of  the  sacrum,  and  the 
parturient  canal  blocked  by  a  firm  tumor  which  extends  from  the  dis- 
placed cervix  to  the  anterior  abdominal  wall. 

Realizing  the  danger  of  a  ventrofixation  in  a  woman  likely  to  become 
pregnant,  different  operators  have  attempted  to  avoid  the  complication 
by  substituting  for  the  firm  fixation  a  loose  suspension  of  the  uterus  by 
adhesive  bands  to  the  anterior  abdominal  wall,  following  the  method  of 
Kelly,  who  sutured  the  fundus  to  the  parietal  peritoneum  and  subperi- 
toneal tissue  rather  than  to  the  fascia  of  the  anterior  abdominal  wall. 
It  was  thought  for  a  time  that  this  would  obviate  the  dangers  of  the 
dystocia  resulting  from  the  ventrofixation.  In  this  connection,  however, 
the  experience  of  the  author^  is  of  interest. 

In  (October,  1902,  a  very  able  New  York  surgeon,  realizing  the  obstet- 
rical dangers  of  a  ventrofixation  performed  with  great  care  a  ventro- 

1  Cragin,  Ventrosuspension  an  Unsafe  Operation  for  Posterior  Displacement  of  the 
Uterus  during  the  Child-bearing  Age,  Trans.  Amer.  Gyn.  Soc,  1908,  xxxiii,  322-327. 


Fig.  379. — Posterior  sacculation  of  the 
uterus  from  ventrofixation. 


630        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

suspension  for  retro\ersion  of  the  uterus  in  the  case  of  ^Irs.  S.,  aged 
twenty-six  years.  She  was  much  benefited  by  the  operation  and  in 
March,  1903,  she  became  pregnant.  On  December  5,  1903,  she  was 
delivered  by  the  autlior  after  a  very  easy  and  ra})id  labor  lasting  only 
two  and  a  half  hours.  In  June,  1907,  she  became  pregnant  again  and 
on  the  eve  of  March  2(),  1908,  the  author  was  again  called  to  deliver 
her.  On  examination  the  following  conditions  were  found.  The  cervix 
was  high  up  posteriorly  and  with  difficulty  reached.  The  child  lay 
t^ans^•ersely  and  the  anterior  uterine  wall  formed  a  muscular  tumor 
obstructing  the  parturient  canal  as  has  so  often  l^een  found  after  a 
ventrofixation.  In  other  words,  the  ventrosuspension  which  in  1903 
allowed  an  easy  delivery  had,  in  the  meantime,  become  a  ventrofixation 
with  obstruction  requiring  a  Cesarean  section  which  was  performed  at 
the  Sloane  Hospital,  :\Iarch  27,  190S. 

From  this  it  is  seen  that  a  ventrosuspension  may  become  a  ventro- 
fixation, and  that  both  ventrofixation  and  ventrosuspension  are  unsafe 
operations  for  women  during  the  child-bearing  age. 

Tumors  of  the  Uterus.  Fibromyomata. — The  most  common  form  of 
uterine  tumor  causing  abnormality  in  labor  is  a  fibromyoma,  a  so-called 
fibroid  of  the  uterus.  Considering  the  frequency  of  fibroids  in  women 
(according  to  Bayle  they  occur  in  20  per  cent,  of  all  women  over  thirty- 
five),  it  is  only  natural  that  they  should  often  be  found  associated  with 
pregnancy,  and  this  notwithstanding  the  fact  that  to  a  certain  extent 
fibroids  predispose  to  sterility. 

In  a  consecutive  series  of  20,000  labors  at  the  Sloane  Hospital  there 
were  89  cases  with  fibroids  large  enough  to  be  noted,  i.  e.,  frequency  of 
1  in  224+  or  0.45  per  cent.  Pinard,^  in  a  consecutive  series  of  13,915 
labors,  reported  84  cases  with  fibroids,  or  a  frequency  of  0.6  per 
cent. 

In  the  author's  series  of  89  cases  there  were  only  11  which  required 
special  treatment  because  of  the  fibroid  itself  and  4  in  which  the  fibroid 
caused  actual  obstruction  to  delivery.  Hence  it  is  seen  that,  although 
the  association  of  fibromyomata  with  pregnancy  is  relatively  a  frequent 
one,  disturbance  by  them  of  the  normal  course  of  labor  is  unusual. 

In  many  cases  the  existence  of  the  tumor  is  first  noted  while  holding 
the  fundus  of  the  uterus  during  or  just  after  the  third  stage  of  a  normal 
labor. 

So  much  depends  upon  the  variety  of  the  fibroid  tumor  which  com- 
plicates pregnancy  that  the  relative  frequency  of  the  different  varieties 
is  of  interest.  In  the  series  of  89  cases  at  the  Sloane  Hospital  41  were 
subperitoneal,  36  were  interstitial,  2  w^ere  submucous,  7  were  subperi- 
toneal and  interstitial  combined,  3  were  interstitial,  subperitoneal  and 
submucous  combined. 

Before  taking  up  the  possible  complications  of  delivery  arising  from 
fibroids  it  is  well  to  study  the  changes  which  take  place  during  pregnancy 
and  the  puerperium. 

1  Fibromes  et  Grossesse,  Annales  de  Gyn.  et  d'Obst.,  1901,  \\\  165-167. 


FIBROMYOMATA  COMPLICATING  PREGNANCY  AND  LABOR     631 

Changes  in  Fibroids. — Physiological  Changes. — During  pregnancy  a 
fibroid,  as  a  rule,  increases  in  size.  In  some  cases  this  increase  is  so  marked 
that  a  tumor  which  cannot  be  detected  before  pregnancy  reaches  the 
size  of  a  lemon  or  an  orange  at  the  time  of  delivery.  This  increase  in 
size  is  brought  about  in  one  of  three  ways:  by  hypertrophy;  by  hyper- 
plasia of  all  its  elements;  by  edema. 

The  tumors  also  change  their  position.  This  is  seen  especially  in  tumors 
situated  in  the  lower  zone  of  the  uterus  or  attached  to  the  cervix,  and  it 
is  fortunate  that  change  in  position  occurs,  for  otherwise  many  more 
cases  of  labor  obstructed  by  fibroids  would  be  met  with.  One  of  the 
most  interesting  provisions  of  nature  is  seen  in  the  gradual  elevation  of 
a  fibroid  situated  low  in  the  pelvis  and  threatening  marked  obstruction 
to  the  parturient  canal. 

Many  a  case  in  which  it  has  seemed  that  Cesarean  section  would  be 
the  only  possible  method  of  delivering  a  living  child  has  demonstrated 
nature's  power  of  dealing  with  the  problem  by  the  gradual  rising  of  the 
tumor  in  the  pelvis  until  it  lies  above  the  brim  and  ceases  to  cause  any 
obstruction  to  the  parturient  canal. 

The  ascent  of  the  tumor  is  brought  about  in  three  ways:  (a)  by  the 
increase  in  size  of  the  tumor,  (b)  by  the  increase  in  size  of  the  uterus,  (c) 
by  the  retraction  of  the  cervix  in  preparation  for  delivery. 

Any  tumor  or  organ  in  the  pelvis,  as  it  increases  in  size  and  finds  the 
pelvic  cavity  cramped  for  its  accommodation,  tends  to  rise  out  of  the 
pelvis.  This  is  seen  in  the  case  of  an  enlarging  ovarian  cys't,  an  enlarging 
uterus,  a  distended  bladder,  etc.  The  increase  in  size  of  the  uterus  with 
its  corresponding  elevation  of  the  site  of  attachment  of  the  fibroid  natu- 
rally tends  to  raise  the  tumor.  Furthermore,  as  the  cervix  is  retracted 
into  the  lower  uterine  segment  and  the  lower  segment  into  the  upper, 
there  is  a  tendency  to  remove  from  its  obstructing  position  the  very 
class  of  fibroids  which  is  most  likely  to  cause  difficulty,  i.  e.,  those 
attached  to  the  lower  portion  of  the  uterus. 

Hence  it  is  that  no  one  should  feel  assured  of  the  absolute  necessity 
of  Cesarean  section  for  the  delivery  of  a  case  complicated  by  a  pelvic 
fibroid  until  it  is  seen  that  the  tumor  is  neither  removed  by  nature  nor 
can  be  pushed  out  of  the  way  by  the  fingers  of  the  obstetrician. 

The  above  changes  in  size  and  position  may  be  regarded  as 
physiological  and  natural  to  pregnancy.  Another  physiological 
change  belongs  to  the  puerperium,  and  that  is  an  involution  or  decrease 
in  size. 

In  some  fibromyomata,  especially  those  approaching  myomata  in 
structure,  an  involution  of  the  tumor  will  accompany  the  involution  of 
the  uterus,,  even  to  the  extent,  in  exceptional  cases,  that  the  examining 
finger  will  be  unable  to  detect  it. 

This  is  illustrated  by  a  case  seen  by  the  author  in  consultation  with 
Dr.  W.  A.  Valentine,  of  New  York,  in  which  at  the  first  labor  there  was 
a  fibroid  tumor  about  the  size  of  a  child's  head  and  there  occurred  a 
most  profuse  postpartum  hemorrhage.  At  the  end  of  a  few  months 
this  tumor  had  become  reduced  to  the  size  of  a  lemon.     During  her 


G32        ABNORMAL  LABOR  FROM  ANOMALIES  IN   PASSAGES 

second  pregnancy  the  tumor  increased  but  little  in  si/e  and  ])ro(luced 
no  complications  in  the  labor. 

When  seen  by  the  author  a  few  mouths  alter  delivery,  he  was  unable 
to  detect  the  tumor. 

There  are  other  changes  in  fibroids  (•omi)licatiug  ])regnancy  and  the 
puerperium  which  can  only  be  looked  ui)on  as  i)athological. 

Pathological  Changes. — These  are  due,  as  a  rule,  to  one  of  three 
causes: 

1.  Disturbed  nutritiou. 

2.  Traumatism. 

3.  Infection. 

Disturbed  Nutrition. — This  is  brought  about  by  some  interference 
with  the  normal  circulation  of  the  tumor  and  may  be  caused  by  some 
change  in  the  vessel  walls,  as  a  sclerosis,  a  stasis  of  the  blood  current, 
or  a  thrombosis.  These  changes  are  especially  apt  to  occur  in  the  puer- 
perium when  retrograde  changes  in  the  uterus  are  taking  place.  Another 
interference  with  circulation  producing  nutritional  changes  results  from 
a  twist  in  the  pedicle  of  the  tumor  which  may  reach  such  a  degree  as  to 
shut  off  all  circulation  from  the  tumor  and  cause  its  necrosis  or  gangrene. 
This  accident  is  also  more  likely  to  occur  during  the  puerperium,  as  with 
the  uterus  emptied  and  reduced  in  size,  the  tumor  has  more  room  to 
move  about  and  produce  a  twist  in  its  pedicle. 

Traumatism. — The  influence  of  traumatism  in  lowering  the  vitality  of 
a  tumor  or  an  organ  and  thus  making  it  more  susceptible  to  the  entrance 
of  infective  organisms  is  well  known.  In  labor  a  fibroid  tumor,  if  of  the 
submucous  or  subperitoneal  ^•a^iety,  especially  the  former,  is  liable  to 
a  considerable  traumatism.  This  is  less  likely  to  occur  if  the  tumor  is 
interstitial.  In  the  puerperium  perhaps  a  tumor  will  be  found  which  has 
been  exposed  to  the  changes  resulting  from  disturbed  nutrition  and  also 
to  traumatism. 

Infection. — A  tumor  with  vitality  thus  lowered  as  a  result  of  pressure 
during  pregnancy,  traumatism  during  labor,  and  disturbed  nutrition 
during  the  puerperium,  is  naturally  liable  to  infection,  especially  in 
the  puerperium,  hence  it  is  that  a  woman  whose  pregnancy  is  compli- 
cated with  a  fibroid  is  not  out  of  all  danger  when  the  labor  is  passed,  for 
the  tumor  may  become  infected  with  the  various  pathogenic  organisms 
which  threaten  a  woman  in  confinement  and  undergo  suppuration.  The 
most  common  of  these  infective  organisms  are  the  streptococcus,  the 
staphylococcus,  the  colon  bacillus,  and  the  gonococcus. 

As  far  as  the  tumor  itself  is  concerned  it  may  undergo  the  following 
changes  as  a  result  of  its  complicating  a  pregnancy  and  labor: 

It  may  become  edematous. 

It  may  undergo  a  fatty  or  myxomatous  degeneration. 

It  may  become  necrotic  or  even  gangrenous. 

It  may  suppurate. 
The  EfEect  of  Fibroids  on  Pregnancy  and   Labor. — The   Effect  on 
Pregnancy. — Sterility. — A  woman  ■s\dth  a  fibromyoma   in  her  uterus 
is  less  likely  to  become  pregnant  than  one  with  a  normal  uterus.    About 


FIBROMYOMATA   COMPLICATING  PREGNANCY  AND  LABOR     633 

twenty-five  per  cent,  of  women  with  fibroids  are  sterile,  and  even  if  not 
absolutely  sterile,  women  with  fibroids  are  apt  to  have  pregnancy  delayed. 

The  sterility  depends  upon  the  location  and  size  of  the  tumor,  the 
condition  of  the  endometrium,  and  the  condition  of  the  tubes  and  ovaries. 

A  submucous  tumor,  even  if  small,  is  more  apt  to  interfere  with  preg- 
nancy than  one  of  the  subperitoneal  variety.  As  a  rule,  however,  the 
larger  the  tumor  the  larger  the  percentage  of  sterility. 

Goetze,  at  the  Greifswald  Clinic,  found  13.6  per  cent,  of  sterility  in 
women  with  small  fibroids,  but  50  per  cent,  in  those  with  tumors  larger 
than  a  child's  head. 

The  sterility  based  upon  the  location  and  size  of  the  tumor  depends 
upon  the  condition  of  the  endometrium.  Thus,  with  a  submucous 
fibroid  there  is  more  endometritis  than  with  one  which  is  subperitoneal. 
Moreover,  a  large  fibroid  usually  encroaches  more  or  less  upon  the  cavity 
of  the  uterus  and  the  endometrium  covering  the  projecting  portion  of 
the  tumor  is  usually  either  hypertrophic  or  atrophic,  not  normal. 

The  tubes  and  ovaries  of  women  suffering  with  fibromyomata  are  usually 
hypertrophied  and  congested  and  seem  to  share  in  the  causation  of  sterility. 

Abortion  and  Premature  Labor. — In  the  experience  of  most  obstetricians, 
pregnancy  complicated  with  a  fibromyoma  has  a  tendency  to  premature 
interruption,  either  as  an  abortion  or  premature  labor.  This,  like  the 
sterility,  is  largely  dependent  upon  the  condition  of  the  endometrium. 

The  presence  of  a  hyperplastic  endometritis  with  its  tendency  to  an 
accidental  hemorrhage  greatly  favors  interruption  of  the  pregnancy. 

In  the  author's  series  of  89  cases  there  were  22  with  premature  labor. 

Pressure  Symptoms. — In  the  case  of  large  fibromyomata  complicating 
pregnancy,  the  pressure  from  the  large  tumor  combined  with  the  large 
uterus  in  the  latter  months  may  produce  great  discomfort  to  the  woman. 
Moreover,  the  pressure  below  upon  the  rectum,  ureters  and  renal  vessels 
and  the  pressure  upward  upon  the  diaphragm  may  so  embarrass  ehmina- 
tion  and  respiration  as  to  demand  serious  consideration.  We  have  thus 
f-ar  studied  the  possible  complications  of  pregnancy  resulting  from  the 
presence  of  fibromyomata.  It  should  be  borne  in  mind,  however,  that,  as 
a  rule,  unless  the  tumor  is  of  considerable  size,  the  pregnancy  progresses 
normally  and  in  many  instances  the  tumor  is  not  detected  until  after 
the  child  is  born. 

Effect  of  Labor. — Fibromyomata  complicating  pregnancy  maj-  influ- 
ence labor  in  three  different  ways.    The  tumor  may: 

1.  Interfere  with  normal  uterine  contractions. 

2.  Cause  abnormal  presentations. 

3.  Cause  obstruction. 

4.  Interfere  with  normal  separation  of  placenta. 

Interference  with  Uterine  Contractions. — Tumors  of  the  interstitial 
and  submucous  type,  seldom  those  of  the  subperitoneal  type,  show  the 
interference  with  uterine  contractions  by  uterine  inertia.  This  tends  to 
give  as  a  result  a  slow  tedious  labor  and  postpartum  hemorrhage. 
Although  the  expected  frequently  does  not  happen,  it  is  hemorrhage 
from  inability  of  the  uterus  to  firmly  contract  and  close  the  bleeding 


634        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

vessels  which  is  the  compHcation  most  expected.    In  the  author's  series 
of  89  cases  there  were  21  cases  of  postpartum  hemorrliage. 

A  tumor  in  the  uterine  wall  separating  the  muscular  fibers  or  a  tumor 
in  the  uterine  cavity  naturally  prevents  the  normal  action  of  the  uterine 
musculature. 

Malprescntatiuns. — A  tibromyoma,  if  of  considerable  size  and  situated 
low  down  in  the  uterus,  is  apt  to  occupy  a  portion  of  the  pelvic  brim  and 
may  prevent  a  normal  vertex  presentation.  The  t^'pes  of  fibromyomata 
most  likely  to  cause  this  malpresentation  are  the  subperitoneal  or  the 
interstitial.  A  submucous  tumor  large  enough  to  cause  obstruction 
would  probably  be  associated  with  sterility.  In  the  author's  series  of 
89  cases  of  fibroids  complicating  pregnancy  there  were  78  cases  of  vertex 
presentation  and  11  with  presentation  other  than  vertex — 12.35  per 
cent,  of  malpresentations. 

Olshausen,^  in  cases  collected  from  the  literature,  found  47  per  cent, 
of  malpresentations. 

As  a  result  of  interference  with  the  normal  entrance  of  the  head  into 
the  pelvic  brim  prolapse  of  the  cord  must  be  looked  upon  as  one  of  the 
possible  results  of  fibroids  complicating  pregnancy  and  labor. 

Fibromyomata  Ohstruding  Labor. — Considering  the  frequency  of  the 
association  of  fibromyomata  with  pregnancy,  it  is  interesting  to  note  how 
seldom  the  tumor  itself  actually  necessitates  operative  delivery. 

In  a  series  of  89  cases  at  the  Sloane  Hospital  there  were  only  1 1  which 
needed  special  treatment  and  in  2  this  consisted  in  simply  pushing  up 
the  tumor  out  of  the  pelvis.  In  the  remaining  9  the  following  operations 
were  performed: 

Hysterectomy,  4. 

Myomectomy,  2. 

Cesarean  section,  1. 

Cesarean  section  and  hysterectomy,  1. 

Craniotomy,  1. 

Adherent  Placenta. — ^The  normal  separation  of  the  placenta  in  a  case 
of  labor  complicated  with  fibroids  is  often  lacking.  This  may  be  caused 
in  two  ways: 

1.  On  account  of  the  absence  of  normal  endometrium  at  the  site  of 
lodgement  of  the  ovum  an  abnormal  decidua  basalis  (serotina)  is  devel- 
oped. 

2.  The  interference  of  the  tumor  with  normal  uterine  contractions 
lessens  the  expulsive  power  of  the  uterus. 

In  the  series  of  89  cases  above  referred  to  there  were  25  cases  of  retained 
secundines. 

Effect  ox  Puerperium. — ^The  presence  of  a  fibromyoma  in  the  uterus 
of  a  woman  just  delivered  tends  to  increase  both  the  after-pains  and  the 
amount  and  duration  of  the  lochia.  These  two  results  follow  from 
interference  with  the  normal  uterine  contractions.  Of  more  consequence, 
however,  is  the  danger  of  degeneration  and  infection  of  the  tumors  which 

'  Myom  und  Schwangerschaft,  Veit's  Handbuch  der  Gyn.,  1897,  xi,  765,  814. 


FIBROMYOMATA   COMPLICATING  PREGNANCY  AND  LABOR     635 

are  favored  by  the  lowered  vitality  and  traumatism  incident  to  the  preg- 
nancy and  labor.  This  degeneration  and  infection  of  the  tumor  may 
take  place  as  a  localized  process  entirely  independent  of  the  ordinary 
uterine  infection,  and  in  case  a  tumor  becomes  tender  and  painful  with 
an  increase  in  temperature  and  pulse  this  should  be  suspected. 

Occasionally  the  acute  process  w^ill  subside  under  the  use  of  the  ice- 
bag,  but  it  usually  indicates  operative  interference. 

Diagnosis. — The  combination  of  fibromyomata  and  pregnancy  is  often 
a  difficult  one  to  diagnose.  On  the  one  hand,  the  irregular  shape  of  the 
uterus  may  be  thought  to  be  due  to  the  asymmetrical  development  of 
the  pregnant  uterus,  and  on  the  other  hand,  the  enlargement  may  be 
assigned  to  the  growth  of  the  tumor.  Irregular  bleeding  which  may 
occur  in  early  pregnancy  as  a  result  of  the  presence  of  the  tumor  may  be 
mistaken  for  menstruation. 

The  diagnosis  is  usually  made  by  noting  that  the  growth  is  more  rapid 
than  that  of  a  fibromyoma,  that  areas  of  softening  such  as  are  expected 
in  pregnancy  appear  in  the  uterine  body,  and  that  the  cervix  gradually 
assumes  the  characteristic  of  the  pregnant  condition. 

The  author  has  seen  cases  of  myomata,  especially  those  of  the  sub- 
mucous type,  in  which  with  abdomen  open,  the  feel  and  appearance  of 
the  uterus  so  resembled  pregnancy  that  this  condition  could  not  be 
positively  excluded  until  the  uterus  was  incised.  As  a  rule  amenorrhea 
and  the  usual  symptoms  of  pregnancy  are  present  to  assist  in  the  diag- 
nosis even  w^hen  this  condition  is  complicated  with  fibromyomata. 

Mortality. — The  prognosis  of  pregnancy  and  labor  complicated  by  the 
presence  of  fibromyomata  in  the  uterus  varies  with  the  size  and  location 
of  the  tumor,  the  surroundings  of  the  patient,  and  the  judgment  and 
skill  of  the  obstetrician  in  charge  of  the  case. 

3.  A  small  fibroid  located  subperitoneally  has  little  effect  upon  pregnancy 
and  labor  and  can  usually  be  disregarded.  Attention  should  be  called 
to  the  fact,  however,  that  fibroids  are  frequently  multiple  and  often 
while  only  one  can  be  felt,  there  may  be  one  or  more  in  the  uterine  wall 
which  may  interfere  more  or  less  with  uterine  contractions.  This  inter- 
ference is  usually  not  enough  to  cause  anxiety.  On  the  other  hand,  a 
tumor  large  enough  to  cause  obstruction  or  one  which  undergoes  necrotic 
changes  presents  one  of  the  serious  problems  of  obstetrics.  As  regards 
the  surroundings  of  a  patient  with  these  complications,  the  low  mor- 
tality of  the  present  day  depends  largely  upon  having  these  patients  either 
in  a  well-equipped  hospital  with  all  modern  provisions  for  maintaining 
asepsis,  or  else  providing  in  the  patient's  home  a  temporary  equipment 
which  will  answer  the  same  purpose.  i\.s  regards  the  judgment  and  skill 
of  the  obstetrician,  there  is  no  complication  of  obstetrics  in  which  greater 
conservatism  is  indicated  than  in  the  association  of  fibromyomata  with 
pregnancy  and  labor,  for  the  reason  that  save  in  exceptional  instances 
nature  is  equal  to  the  solution  of  the  problem.  A  few  observations  on 
this  subject  may  be  of  value:  In  the  first  place  fibromyomata  sometimes 
cause  abortion,  or  artificial  abortion  may  in  rare  instances  be  indicated 
in  this  complication. 


036        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

The  complete  emptying  of  the  uterus  in  an  al)ortion  compHcated  by 
fibroids  is  a  mucli  more  serious  operation  than  with  a  normal  uterus. 
The  tortuous  canal,  the  adherence  of  the  membranes,  and  the  tendency 
to  hemorrhage,  all  unite  to  make  the  technic  more  difficult.  In  some 
cases  the  hemorrhage  can  only  be  checked  b\'  a  hysterectomy.  Further- 
more, if  the  tumor  is  of  the  submuc-ous,  and  sometimes  e\en  of  the  inter- 
stitial variety,  the  operation  may  so  injure  the  capsule  of  the  tumor  that 
necrosis  and  infection  fol'ows.  While  conservatism  has  been  advocated, 
as  a  general  rule  in  the  treatment  of  the  complication  under  considera- 
tion, if  the  tumor  undergoes  necrosis,  only  prompt,  radical  work  in  the 
shape  of  myomectomy  or  hysterectomy  will  keep  the  mortality  low. 

Maternal  Mortality. — In  the  89  cases  of  fibromyomata  occurring  in 
20,000  consecutive  labors  at  the  Sloane  Hospital  there  were  3  maternal 
deaths,  i.  e.,  3.3  per  cent.  Of  these  3  deaths,  1  occurred  from  toxemia  of 
pregnancy,  1  from  nephritis,  and  1  from  sepsis  from  sloughing  of  the 
tumor. 

Pinard,  in  his  series  of  84  cases,  reported  a  maternal  mortality  of  3.G 
per  cent. 

Fetal  Mortality. — Aside  from  the  fetal  mortality  resulting  from  abor- 
tion and  premature  labor,"  there  is  always  danger  to  the  fetus  from  the 
endometritis  favoring  accidental  hemorrhage;  from  prolapse  of  the  cord 
when  the  tumor  interferes  with  normal  engagement  of  the  presenting 
part;  from  toxemia  when  the  tumor  is  large  enough  to  interfere  by  its 
pressure  with  elimination,  and  from  the  operative  delivery  when  the 
tumor  causes  obstruction. 

In  the  author's  series  of  89  cases  there  were  31  fetal  deaths;  4  from 
abortion,  IS  stillbirths,  and  9  subsequently,  but  before  the  mothers  left 
the  hospital.    This  gave  a  fetal  mortality  of  34.8  per  cent. 

Treatment. — In  discussing  the  treatment  of  fibromyomata  complicat- 
ing pregnancy  and  labor,  it  is  only  right  to  antedate  this  condition 
and  consider  the  case  of  an  unmarried  woman  who  is  contemplating 
matrimony. 

What  advice  should  be  given  her?  This  depends  largely  upon  the  size 
of  the  tumor.  The  first  question  which  naturally  presents  itself  is  this: 
Should  a  woman  with  a  fibromyoma  of  the  uterus  marry  ?  This  question 
has  been  asked  of  the  author  a  number  of  times,  and  he  has  each  time 
answered  it  in  the  affirmative  and  has  never  regretted  it. 

Other  questions  presenting  themselves  may  be  these :  Should  anything 
be  done  to  the  tumor  before  marriage?  Is  childbirth  possible?  What 
will  be  the  effect  of  pregnancy  upon  the  tumor?  The  answers  to  these 
questions  depend  largely  upon  the  size  and  location  of  the  tumor 
or  tumors.  If  the  tumor  is  subperitoneal,  is  small  and  is  causing  no 
symptoms,  the  author  believes  that  the  woman  should  be  allowed  to 
marry  and  that  she  is  fortunate  if  she  is  ignorant  of  the  existence  of  the 
growth. 

If  the  tumor  is  of  large  size  and  is  causing  symptoms,  either  hemor- 
rhage, pain  or  other  pressure  symptoms,  or  is  seen  to  be  increasing  in 
size,  the  problem  is  a  difficult  one.    In  the  solution  of  it  several  factors 


FIBROMYOMATA   COMPLICATING  PREGNANCY  AND  LABOR    637 

should  be  borne  in  mind,  when  considering  matrimony.  In  the  first 
place,  while  fibromyomata  have  a  certain  degree  of  sterility,  still  preg- 
nancy is  possible,  and  during  the  pregnancy  the  tumor  will  probably 
increase  in  size. 

With  these  facts  in  mind  the  author  believes  that  if  the  tumor  is  large 
enough  to  cause  symptoms  and  is  either  subperitoneal  or  submucous 
and  can  be  removed  without  hysterectomy,  this  should  be  done  before 
marriage. 

The  next  question  is :  What  should  be  done  if  the  tumor  is  large  enough 
to  produce  symptoms,  yet  is  so  situated  that  it  cannot  be  removed 
without  removing  the  body  of  the  uterus?  The  author  believes  that 
here  the  best  treatment  is  supravaginal  hysterectomy  before  marriage, 
leaving  at  the  operation,  the  ovaries,  tubes,  and  cervix.  This  allows  the 
woman  to  ovulate  and  retain  the  benefits  of  the  ovarian  function.  It 
also  retains  the  normal  condition  of  the  vagina.  In  fact  it  retains  the 
conditions  for  normal  marital  relations.  Of  course  the  woman  will 
be  unable  to  become  a  mother,  and  the  would-be  husband  should  be 
informed  of  this  before  marriage,  but  the  presence  of  the  tumor  in  all 
probability  robbed  her  of  the  blessing  of  maternity  long  before  the  opera- 
tion and  she  is  in  much  better  condition  for  matrimony  after  operation 
than  before. 

In  the  consideration  of  the  management  of  the  case  of  a  w^oman  who 
is  already  pregnant  when  first  seen  by  the  obstetrician,  one  of  the  first 
questions  which  may  arise  is  this:  Shall  the  tumor  receive  any  treat- 
ment during  pregnancy?  This  cjuestion  the  author  believes  should  be 
answered  in  the  negative  unless  the  tumor  obstructs  the  parturient 
canal,  or  necrosis  of  the  tumor  is  threatened.  If  the  tumor  is  situated 
in  the  cervical  canal  and  is  pedunculated,  it  should  be  removed  with 
the  hope  that  the  pregnane}'  will  not  be  interfered  with.  If  the  tumor 
is  subperitoneal  and  threatens  obstruction,  a  condition  is  presented 
which  may  tax  the  judgment  of  the  obstetrician  to  the  utmost.  While 
a  few  cases  may  well  be  treated  by  myomectomy  during  pregnancy, 
the  author  believes  this  to  be  very  exceptional  and  in  general  not  good 
practice.  Fig.  380  is  the  photograph  of  a  tumor  attached  to  the  fundus 
and  threatening  obstruction.  It  was  removed  by  the  author  by  myo- 
mectomy when  the  woman  was  two  months  pregnant,  the  pregnancy 
not  being  interrupted.  In  the  majority  of  cases  the  tumor  will  either  be 
pulled  up  out  of  the  way  by  nature  as  the  pregnancy  advances,  or  can  be 
pushed  out  of  the  way  by  the  gentle  manipulation  of  the  obstetrician. 
Furthermore,  during  pregnancy  is  not  a  favorable  time  to  operate  upon 
the  uterus,  as  the  risk  of  hemorrhage  and  infection  is  greater  and  the 
tendency  to  abortion  too  great  to  be  lightly  overlooked. 

In  the  majority  of  cases  the  pregnant  uterus  containing  one  or  more 
fibroids  should  be  left  alone  until  nature  has  demonstrated  in  her 
labor  that  she  is  unable  to  remove  the  obstruction  and  complete  the 
delivery.  In  many  cases  during  the  labor  itself  the  tumor  will  be  seen 
to  rise  and  cease  to  obstruct.  The  waiting  observation  of  the  obstet- 
rician, however,  should  be  intelligent  and  it  should  ever  be  borne  in  mind 


638        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

that  long-continued  and  forcible  pressure  upon  the  tumor  fa\'ors  necrosis 
and  infection  and  endangers  the  mother  more  than  a  timely  clean 
operation. 

If  early  in  the  first  stage  of  labor  the  parturient  canal  is  foimd  to  be 
distinctly  obstructed  liy  the  tumor,  the  best  treatment  is  usually  a 
Cesarean  section  followed  l)y  a  myomectomy  or  h>sterectomy,  as  the 
conditions  indicate. 

A  variety  of  problems  may  be  presented  to  the  obstetrician  by  the  com- 
plication of  pregnancy  by  fibroids  of  large  size.  One  may  be  the  advis- 
ability of  operating  during  pregnancy  and  removing  uterus  and  fetus 


■**fi8»* 


'»  •>* 


\ 


> 


Fig.  380. — Fibroinxoina  rcmuxed  from  luiidu.-?  of  two  iiiuuths  prcguaut  ultTu? 

not  interrupted. 


ricguancy 


before  its  viability,  \yhile  instances  ma>-  arise  where  the  pressure  of 
the  growing  uterus  and  tumor  is  such  as  to  endanger  the  life  of  the  mother 
and  disregard  of  the  life  of  the  fetus  is  justifiable,  in  general  it  may  be 
said  that  the  difference  in  mortality  between  a  simple  Cesarean  section 
and  one  followed  })y  hysterectomy  is  so  slight  in  a  clean  case,  that  the 
best  procedure  in  skilled  hands  and  with  modern  equipment  is  to  let 
the  pregnancy  go  to  term,  deliver  by  Cesarean  section,  and  then  deal 
with  the  tumor  according  to  the  conditions  found. 

4.  Another  problem  may  present  itself:    In  the  case  of  an  early  preg- 
nancy complicated  by  a  fibromyoma  which  has  never  caused  symptoms, 


OVARIAN   TUMORS  COMPLICATING  PREGNANCY  AND  LABOR     639 

is  it  justifiable  to  empt}^  the  uterus  to  avoid  the  probable  growth  of  the 
tumor? 

While  conditions  may  arise  in  which  such  a  procedure  is  justifiable, 
it  is  usually  very  exceptional,  and  the  author  has  usually  advised  against 
it,  both  on  moral  grounds  and  for  the  reason  that  the  induction  of  abor- 
tion in  the  case  of  a  fibroid  uterus  is  an  operation  of  greater  danger  than 
is  usually  supposed.  As  regards  the  question  of  operation  upon  fibro- 
myomata  during  the  puerperium,  it  may  be  said  that  unless  the  circula- 
tion of  the  tumor  is  suddenly  obstructed,  as  by  a  twist  of  the  pedicle,  or 
the  tumor  becomes  necrotic  or  infected,  the  puerperium  is  not  a  good 
time  for  operation.  It  is  much  better  to  wait  until  involution  in  the 
uterus  and  the  tumor  is  complete,  when  the  ease  of  operation  will  be 
increased  and  the  risk  diminished.  Moreover,  in  some  cases  the  need 
for  operation  will  be  found  to  have  disappeared. 

A  twist  in  the  pedicle  of  a  fibromyomata  with  acute  symptoms  from 
its  strangulation  and  inflammation  indicates  operation  at  once,  whether 
it  occurs  during  pregnancy  or  the  puerperium.  Furthermore,  the  oc- 
currence of  necrosis  or  suppuration  of  the  tumor  as  a  result  of  the  labor 
demands  speedy  radical  operation. 

Carcinoma  of  the  Uterus. — Occasionally  a  neglected  carcinoma  of  the 
cervix  will  so  infiltrate  the  surrounding  tissue  as  to  cause  marked  obstruc- 
tion to  delivery.  In  one  case  of  the  author's  this  obstruction  was  so 
extreme  and  the  danger  of  hemorrhage  from  laceration  of  the  cancerous 
tissue,  if  craniotomy  was  attempted,  was  so  great  that  in  spite  of  the 
child  being  dead  Cesarean  section  was  performed. 

Ovarian  Tumors. — ^Tumors  of  the  ovary  present  a  serious  complication 
in  pregnancy  and  labor,  not  only  on  account  of  possible  dystocia,  but  also 
on  account  of  possible  changes  taking  place  in  the  tumor  itself. 

Although  solid  tumors  of  the  ovary  occasionally  occur,  McKerron^ 
finding  in  the  literature  5  fibromata  in  a  series  of  107  cases  of  ovarian 
tumor  complicating  pregnancy,  it  is  the  cystic  tumor,  either  the  cyst- 
adenoma  or  the  dermoid,  which  is  most  often  found  complicating  preg- 
nancy and  labor. 

Diagnosis. — An  ovarian  cyst  is  usually  diagnosed  by  its  elastic  feel,  its 
spherical  or  multilocular  shape,  its  relation  to  the  uterus,  and  the  history 
of  the  patient.  In  this  connection  attention  should  be  drawn  to  the  fact 
that  a  tense  cyst,  or  one  under  pressure,  may  lose  its  elastic  feel  and  be 
mistaken  for  a  solid  tumor.  The  natural  position  for  a  small  ovarian 
tumor  is  first  at  the  side  of  the  uterus,  then  in  the  pouch  of  Douglas,  then 
as  its  size  becomes  too  great  for  the  pouch  of  Douglas,  unless  it  has  formed 
adhesions  there,  it  naturally  rises  into  the  abdomen.  If  it  has  formed 
adhesions  in  the  pouch  of  Douglas,  or  has  become  incarcerated  there, 
or  if  it  is  an  intraligamentous  cyst,  it  retains  its  position  and  is  more 
likely  to  cause  dystocia.  A  dermoid  cyst,  from  its  greater  weight  and 
greater  tendency  to  form  adhesions,  is  more  likely  to  be  found  low  in  the 
pelvis.     A  knowledge  of  the  behavior  of  these  different  varieties  and 

1  The  Obstruction  of  Labor  by  Ovarian  Tumors  in  the  Pelvis,  Trans.  London  Obst.  Soc. , 
1897,  xxxix,  334-382. 


040        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

conditions  of  ovarian  cysts  greatly  assists  in  the  diagnosis  of  an  ()\arian 
tumor  complicating  pregnancy. 

Occasionally  an  ovarian  cyst  will  simulate  ])regnancy.  The  author 
once  saw  in  consultation  an  inmate  of  an  institution  for  the  feeble- 
minded who  presented  many  of  the  symptoms  of  pregnancy  and  was 
suspected  of  being  in  that  condition  as  a  result  of  rape  by  one  of  the 
orderlies  of  the  institution.  The  girl  had  an  enlarged  abdomen,  darkened 
areolae,  fluid  in  the  breasts  and  amenorrhea.  Careful  examination,  how- 
ever, detected  a  small  uterus,  separate  from  a  large  ovarian  cyst,  which 
was  later  verified  by  an  operation.  The  changes  in  the  breasts  were 
due  to  the  ovarian  stimulation  from  the  growth  of  the  tumor  and  the 
amenorrhea  was  due  to  her  anemia. 

Effect  on  Pregnancy. — Most  obstetricians  agree  that  abortion  and 
premature  labor  are  more  common  in  a  pregnancy  associated  with  an 
ovarian  cyst.  Remy,^  in  a  series  of  321  pregnancies  complicated  by 
ovarian  tumors  collected  from  the  literature,  found  abortion  or  premature 
labor  reported  in  17  per  cent.  The  complication,  however,  most  to  be 
dreaded  in  pregnancy  is  some  change  in  the  cyst  itself,  as  a  strangulation 
from  a  twist  in  its  pedicle.  The  change  in  the  shape  and  size  of  the  uterus 
usually  necessitates  a  change  in  the  position  of  the  tumor  with  the  risks 
of  a  twist  in  its  pedicle,  if  it  is  a  pedunculated  tumor.  This,  however,  is 
less  likely  to  occur  in  pregnancy  than  in  the  puerperium. 

Effect  of  Labor. — An  ovarian  tumor  may  or  may  not  cause  dystocia, 
according  to  its  relation  to  the  parturient  canal.  If  small  and  situated 
above  the  pelvis  it  is  not  likely  to  interfere  with  the  labor,  but  if  situated 
in  the  pouch  of  Douglas,  or  if  intraligamentous  and  lying  low  in  the 
pelvis,  it  may  cause  most  marked  obstruction. 

Although  the  tumor  may  not  interefere  with  the  labor,  if  it  lies  above 
the  pelvis  the  labor  often  so  interferes  with  its  circulation  and  vitality 
as  to  cause  future  trouble. 

Effect  on  the  Puerperium. — The  fact  that  the  labor  has  been  com- 
pleted does  not  necessarily  signify  that  the  danger  from  a  complicating 
ovarian  tumor  is  over.  The  tumor  may  have  been  bruised  during  the 
labor  with  the  consequent  lowering  of  vitality  and  greater  risk  of  infection, 
or  following  the  labor,  with  the  increased  room  for  changing  its  position 
the  tumor  may  become  twisted  on  its  pedicle  with  the  acute  symptoms 
belonging  to  that  condition. 

If  it  is  known  that  a  woman  has  an  ovarian  tumor,  the  puerperium 
shoidd  be  carefully  watched  and  the  occurrence  of  acute  pain,  \'omiting 
and  symptoms  of  peritoneal  irritation  with  tenderness  over  the  tumor 
and  a  rise  of  temperature  and  pulse  should  be  taken  as  evidence  that  the 
circulation  of  the  tumor  has  become  obstructed  and  an  abdominal 
operation  should  be  performed  promptly  with  removal  of  the  tumor. 

Treatment. — An  ovarian  tumor  complicating  pregnancy  in  its  early 
half  should  be  removed.  It  is  admitted  that  in  15  to  20  per  cent,  of  the 
cases  the  operation  is  followed  by  abortion  or  premature  labor,  but  these 

'  De  La  Giosscssc  coinpli(iuee  dc  Kj'ste  ovariquc,  Paris,  1S86. 


OVARIAN   TUMORS  COMPLICATING  PREGNANCY  AND  LABOR     G41 


results  are  not  unusual  in  the  complication  of  pregnancy  by  an  ovarian 
tumor  even  without  the  operation  for  its  removal.  The  route  to  be 
followed  in  the  operation  depends  upon  the  size  and  the  location  of  the 
tumor. 

In  general  the  abdominal  route  is  preferable,  but  in  two  instances,  one 
with  a  cystadenoma  and  the  other  with  a  dermoid  cyst,  the  author  has 
removed  the  tumor  per  vaginam  without  interference  with  the  course  of 
pregnancy. 

The  above  general  rule  the  author  believes  applies,  unless  the  tumor 
is  so  small  as  to  be  disregarded,  until  the  pregnancy  is  six  months 
advanced. 


Fig.  381. — Oyaiian  tumor  obstructing  th6  parturient  canal.      (Bumm.) 

During  the  last  three  months  the  question  of  operation  is  a  debatable 
one  and  usually  it  is  better  to  keep  the  patient  under  careful  observa- 
tion and  postpone  the  operation  until  after  -the  labor,  unless  the  latter  is 
obstructed  by  the  tumor,  or  the  circulation  and  nutrition  are  disturbed. 
The  reason  for  this  view  is  based  upon  the  fact  that  during  the  latter 
part  of  pregnancy  the  operation  is  often  difficult,  especially  if  the  tumor 
lies  behind  the  uterus  (Fig.  381),  the  incision  often  has  to  be  a  long  one 
and  the  inevitable  manipulation  favors  premature  delivery.  When  the 
labor  is  obstructed  by  the  tumor  the  question  arises :  Shall  it  be  tapped 
or  shall  it  be  removed?  It  is  admitted  that  if  the  cyst  content  is  thin, 
clear  fluid,  as  obtains  in  some  ovarian  and  parovarian  cysts,  the  cyst 
can  be  emptied  and  the  labor  terminated  without  an  abdominal  opera- 
tion. Years  ago  the  author  treated  cases  in  that  way,  but  the  difficulty 
on  the  one  hand  in  determining  that  the  cyst  content  is  clear  and  rela- 
41 


642        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

lively  harmless  and  the  danger  on  the  other,  of  infecting  the  peritoneum 
if  the  tumor  is  a  dermoid,  or  the  cyst  fluid  infected,  has  led  to  the  abandon- 
ment of  this  method  and  most  operators  are  agreed  that  the  best  procedure 
is  the  removal  of  the  tumor  if  operative  skill  is  at  hand  or  ol)tainable. 
As  a  rule,  if  an  ovarian  tumor  obstructs  the  labor,  the  best  procedure  is 
the  combination  of  an  ovariotomy  with  a  Cesarean  section. 
'  To  remove  an  ovarian  tumor  by  abdominal  incision  during  a  labor 
and  then  allow  the  sutured  incision  to  be  subjected  to  the  strain  incident 
to  the  completion  of  the  labor  by  nature,  does  not  appeal  to  the  author 
as  good  practice.  Furthermore,  in  his  experience  the  ovarian  tumors 
causing  obstruction  are  usually  situated  behind  the  uterus  and  are  much 
easier  reached  and  better  treated  after  the  uterus  has  been  emptied. 

The  author's  preference  is  usually  to  perform  a  Cesarean  section  and 
follow  it  by  the  ovarian  operation. 

The  indication  for  operation  upon  an  ovarian  tumor  during  the  puer- 
perium  is  based  upon  the  condition  of  the  tumor  itself.  If  as  a  result  of 
the  labor  it  becomes  inflamed  or  infected,  or  if  a  twist  of  its  pedicle 
occurs,  the  tumor  should  be  removed  at  once,  otherwise  it  may  be  left 
until  the  woman  has  regained  her  strength  and  her  uterus  has  involuted. 

Dystocia  from  Kidney. — Although  obstruction  to  labor  arising  from 
the  kidney  or  kidneys  is  a  rare  complication,  still  in  6  instances  the  author 
has  met  with  obstruction  of  the  parturient  canal  from  a  congenitally 
displaced  kidney.  In  the  first  instance,  in  a  case  seen  in  consultation 
with  the  late  Dr.  T.  Gaillard  Thomas  and  Dr.  H.  ]Mc]M.  Painter,  of  New 
York,  the  patient  was  at  term,  and  filling  the  pelvis  posteriorly  and  to 
the  left  side  was  a  congenitally  displaced  kidney  in  the  condition  of 
hydronephrosis. 

This  was  removed  by  the  author^  per  vaginam.  The  operation  was 
followed  within  twelve  hours  by  uterine  contractions  and  the  child  was 
born  normally  on  the  following  day.  A  few  years  later  he  attended  this 
woman  in  a  labor  which  was  absolutely  normal. 

In  the  other  5  instances  of  labor  obstructed  by  congenitally  displaced 
kidneys  both  kidneys,  lay  in  the  pelvis,  and  in  each  case  Cesarean  section 
was  performed  without  disturbing  the  kidneys.  These  5  instances 
occurred  in  the  same  patient. 

Calculi  in  the  Bladder.- — Occasionally,  as  reported  by  Love,^  a  calculus 
in  the  bladder  may  obstruct  labor  from  its  size  and  position.  In  Dr. 
Love's  case  the  calculus  became  so  wedged  between  the  presenting  part 
and  the  Del  vis  that  the  child  had  to  be  delivered  by  Cesarean  section. 
As  a  rule  the  best  procedure  is  to  relieve  the  obstruction  by  removing 
the  calculus. 

Cancer  of  the  Rectum.^ — As  in  cancer  of  the  cervix  so  in  cancer  of  the 
rectum,  the  connective  tissue  in  the  pelvis  may  become  so  infiltrated  by 
the  disease  as  to  produce  an  unyielding  mass  impassable  for  the  child 
without  great  danger  of  extensive  laceration  and  hemorrhage. 

1  Congenital  Peh-ic  Kidney  Obstructing  the  Parturient  Canal,  Amer.  Jour.  Obst.,  1898, 
xxx^-iii,  36-41. 

2  Trans.  Alumni  Soc.  Sloane  Mat.  Hosp.,  I'JIO,  pp.  1  and  2. 


DYSTOCIA  FROM  CONDITIONS  OF   THE  CERVIX  643 

In  cases  of  this  kind,  in  spite  of  the  fact  that  the  woman  has  but  a 
short  time  to  live,  if  the  obstruction  is  marked.  Cesarean  section  is  the 
best  method  of  delivery.  It  may  be  noted,  however,  that  the  mortality 
from  Cesarean  section  in  this  class  of  cases  is  high. 

Aside  from  the  causes  of  obstruction  already  mentioned,  other  tumors, 
malignant  or  benign,  will  occasionally  occlude  more  or  less  the  parturient 
canal  and  require  either  their  removal  or  Cesarean  section. 

Dystocia  from  Conditions  of  the  Cervix. 

Atresia  of  the  Cervix. — Occasionally  on  vaginal  examination  to  deter- 
mine the  amount  of  cervical  dilatation  no  cervix  and  no  os  uteri  will 
be  detected,  but  a  thin  muscular  diaphragm  will  stretch  across  the 
vaginal  vault,  separating  the  presenting  part  from  the  examining 
fingers. 

This  is  often  confusing  in  diagnosis,  as  the  usual  landmarks  are  obscured. 
Of  course  there  was  an  opening  present  when  impregnation  occurred,  and 
the  present  atresia  is  the  result  of  inflammation  of  the  cervical  canal 
which  has  taken  place  since.  Sometimes  this  atresia  has  followed  a 
previous  amputation  of  the  cervix,  but  more  often  the  atresia  is  the 
result  of  an  inflammation  of  the  canal  of  a  cervix  which  has  been  retracted 
and  flattened  out  in  nature's  eftort  to  find  and  dilate  the  opening.  Some- 
times the  atresia  is  only  apparent  and  there  is  present  a  very  small  and 
very  rigid  external  os. 

It  is  interesting  to  observe  that  in  some  of  these  cases  of  atresia  of 
the  cervix  the  labor  will  continue  for  hours  without  progress  so  long  as 
the  atresia  is  complete,  but  as  soon  as  a  small  opening  is  made,  complete 
dilatation  is  accomplished  within  a  very  short  time  and  the  labor  pro- 
gresses rapidly. 

Diagnosis. — If  the  possibility  of  this  condition  is  borne  in  mind  the 
diagnosis  usually  presents  little  difficulty.  Generally,  if  a  careful  examina- 
tion be  made,  the  representative  of  the  cervix  and  the  place  where  the 
external  os  should  be  can  be  felt. 

Treatment. — Having  made  the  diagnosis  of  the  condition  the  treatment 
is  usually  easy.  It  consists  simply  in  making,  with  some  sterile  instru- 
ment, an  artificial  opening  where  the  external  os  should  be.  Sometimes 
the  sterile-gloved  finger  will  suffice  to  make  the  opening,  but  often  a 
sharper,  firmer  instrument  will  be  necessary. 

Stenosis  of  the  Cervix. — Aside  from  an  atresia  of  the  cervix,  dystocia 
may  arise  from  a  narrowing  or  an  excessive  rigidity  of  the  cervical  canal. 
This  may  be  the  result  of  lack  of  development,  of  previous  operation,  of 
traumatism,  or  ulceration  with  cicatrization. 

From  Faulty  Development. — The  same  cases  which  on  account  of  lack 
of  development  in  the  uterus  suffer  from  dysmenorrhea  during  girlhood 
and  perhaps  from  sterility  after  marriage,  and  which  present  on  examina- 
tion an  anteflexed  uterus,  perhaps  with  an  elongated  cervix,  often  exhibit 
in  labor  a  stenosis  of  the  cervix  and  a  delay  in  dilatation  amounting  to 
dystocia.    This  condition  is  really  the  result  of  lack  of  development,  and 


644        ABXORMAL  LABOR  FROM  AXOMALIES  IX   PASSAGES 

the  mechanical  dihitation  of  the  cervix  ^A•hich  enables  them  to  become 
pregnant  may  be  looked  upon  as  an  aid  to  the  further  development  of  the 
uterus. 

When  the  stenosis  of  the  cervical  canal  is  overcome  by  one  labor  the 
subsequent  labors  usually  progress  normally.  In  elderly  primigravidse 
is  occasionally  met  a  rigidity  of  the  cervix  which  from  its  difficulty  in 
dilatation  resembles  the  stenosis  of  the  cervix  just  described. 

From  Previous  Operation. — Every  gynecologist  should  attend  a  certain 
number  of  deli\eries  in  women  upon  whom  he  has  performed  the  opera- 
tion of  trachelorrhaphy.  In  this  way  onh'  can  he  properly  appreciate  the 
importance  of  leaving  in  his  operations  for  lacerated  cervix,  in  women 
who  are  likely  to  have  other  children,  sufficient  cer\ical  tissue  and  a 
cervical  canal  sufficiently  large  for  a  relatively  normal  dilatation.  It  is 
one  of  the  trying  experiences  of  the  obstetrician  to  meet  in  labor  a  cervix 
which  has  been  previously  repaired,  perhaps  with  a  beautiful  cosmetic 
result,  but  with  a  rigidity  from  lack  of  surrounding  tissue  which  can 
only  be  overcome  by  unnecessary  hours  of  labor,  or  perhaps  by  mechan- 
ical dilatation  which  leaves  a  cervix  in  a  worse  state  of  laceration  than 
that  for  which  the  original  operation  was  performed.  It  is  better  in  a 
trachelorrhaphy,  in  women  during  the  child-bearing  age,  to  leave  an 
external  os  rather  luiduly  patulous  than  to  suture  it  too  tightly.  Atten- 
tion has  already  been  called  to  the  fact  that  as  a  result  of  a  previous  am- 
putation of  the  cervix  a  certain  amount  of  dystocia  may  residt  from  a 
cicatricial  os.    As  a  rule,  however,  this  does  not  occur. 

From  Traumatism. — Occasionally  a  difficult  instrumental  delivery  is 
accompanied  by  so  much  traumatism  and  followed  by  so  much  slough- 
ing and  cicatrization  that  a  subsequent  dystocia  results  from  the  stenosis 
and  rigidity  thus  produced. 

From  Ulceration. — The  extensive  use  of  caustics,  either  chemical  caus- 
tics or  the  actual  cautery,  and  diseases  which  are  characterized  by  ulcera- 
tion with  subsequent  cicatrization  when  the  disease  is  cured,  as  for 
instance  syphilis,  may  result  in  a  cicatricial  condition  of  the  cervix 
causing  dystocia,  which  can  only  be  overcome  by  mechanical  dilatation. 

Treatment. — When  labor  is  prolonged  on  account  of  a  stenosed  or 
excessively  rigid  cervix,  two  general  methods  of  treatment  are  at  the 
command  of  the  obstetrician:    (a)  medicinal,  (b)  mechanical. 

Medicinal  Treatment. — A  woman  whose  first  stage  has  been  unduly 
prolonged  and  whose  cervix  for  reasons  under  discussion  is  still  undilated, 
is  usually  tired  out  both  physically  and  mentally  and  needs  rest.  Chloral 
(grs.  xx)  per  rectum  or  a  hypodermic  injection  of  morphin  sulph. 
(gr.  \-\),  ANill  often  give  the  needed  rest  of  two  or  three  hours,  and  if  a 
little  hot  broth  or  some  easily  digested  food  is  then  administered  and 
encouragement  given,  the  patient  will  often  renew  her  labor  with  increased 
vigor  and  rapidly  complete  her  first  stage. 

If  the  uterine  muscle  shows  inertia  and  appears  to  be  unequal  to 
the  task  of  dilating  the  cervix,  two  drugs  are  of  value:  quinine  and 
strychnin. 

The  administration  of  ciuinine  sulph.  fgr.  v,  q.  4  h.)  and  strychnin 


DYSTOCIA   FROM  CONDITIONS  OF   THE  CERVIX  645 

sulpli.  (gr.  ^-^  q.  4  li.),  alternating  ^Yith  each  other,  will  stimulate  the 
rhythmical  contractions  of  the  uterus  better  than  any  other  medication 
known  to  the  author. 

Some  obstetricians  favor  repeated  vaginal  douches  of  hot  lysol  solu- 
tion (0.5  per  cent.)  for  their  softening  effect  upon  the  cervix  and  vagina. 

It  must  be  borne  in  mind,  however,  that  the  introduction  of  a  douche 
nozzle,  or  any  other  foreign  substance  into  the  vagina  during  labor, 
increases  the  risk  of  infection.  The  use  of  pituitary  extract  before  the 
cervix  is  dilated  is  neither  safe  nor  wise. 

Mechanical  Treatment.- — If  in  spite  of  rest  of  the  patient  and  medicinal 
stimulation  of  the  uterine  muscle,  the  cervix  still  resists  dilatation,  there 
is  nothing  quite  equal  to  the  use  of  the  elastic  bag,  as  described  on  page 
616.  The  presence  of  the  bag  in  the  cervical  canal  not  only  softens  and 
dilates  the  cervix,  but  stimulates  uterine  contractions  and  has  proved 
itself  a  method  of  such  great  value  that,  save  for  giving  the  patient 
rest,  medicinal  methods  of  dealing  with  a  stenosed  or  rigid  cervix  in  labor 
have  fallen  more  and  more  into  disuse  and  the  elastic  bags  are,  as  a 
rule,  promptly  resorted  to. 

After  the  cervix  has  been  softened  and  partially  dilated  by  nature  or 
by  the  use  of  the  elastic  bag,  its  further  dilatation,  if  nature  is  unequal 
to  the  task,  may  be  accomplished  by  gentle  and  gradual  stretching  with 
the  gloved  fingers.  This  must  be  done  carefully,  as  in  some  instances 
extensive  laceration  and  profuse  hemorrhage  have  resulted. 

Septa  of  Cervix. — Referring  to  the  development  of  the  uterus  (see 
page  47),  it  is  seen  that  it  is  formed  by  a  union  of  the  two  ducts  of  Miiller 
which  lie  side  by  side,  and  that  in  the  normal  development  the  partition 
formed  by  the  two  approximated  walls  is  absorbed,  leaving  a  single  canal 
for  the  uterine  body  and  cervix.  Sometimes,  as  a  result  of  faulty  devel- 
opment, there  is  an  arrest  in  the  absorption  of  this  partition  and  a  band 
is  left  running  anteroposteriorly  for  a  variable  height  across  the  cervical 
canal.  The  dystocia  arising  from  this  band  is  seldom  of  any  consequence, 
as  although  it  can  sometimes  be  felt  running  anteroposteriorly  across  the 
presenting  part,  it  usually  stretches  easily,  as  nature  selects  one  opening 
or  the  other,  or  it  can  be  cut,  or  slipped  to  one  side  by  the  obstet- 
rician. 

Another  variety  of  septum  in  the  cervical  canal  sometimes  results 
from  faulty  union  in  a  trachelorrhaphy.  The  union  at  the  site  of  one 
or  more  sutures  may  fail,  and  instead  of  leaving  only  one  os  uteri,  the 
operation  may  result  in  two  openings,  with  a  septum  between  which  in 
a  subsequent  labor  may  resemble  that  found  from  faulty  development. 
It  is  treated  in  the  same  way.  Sometimes,  as  a  result  of  extensive  lacera- 
tion, sloughing  and  cicatrization,  similar  bands  or  septa  may  result. 

Edema  of  the  Anterior  Lip, — Occasionally  before  the  dilatation  of  the 
cervix  is  complete  the  anterior  lip  is  caught  between  the  fetal  head  and 
the  anterior  pelvic  wall  and  becomes  quite  edematous.  While  usually 
this  disappears  as  the  dilatation  progresses,  this  process  can  often  be 
facilitated  by  upward  pressure  upon  it  with  the  gloved  fingers  between 
and  during  two  or  three  uterine  contractions.    The  pushing  downward 


646        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

and  forward  of  the  undilated  cervix  by  the  advancing  head  tends  to 
loosen  the  attachments  of  the  anterior  vaginal  wall  and  favor  cystocele; 
hence  the  desirability  of  lessening  this  if  possible. 

Dystocia  from  Conditions  of  the  Vagina  or  Vulva. 

Atresia. — Complete  atresia  of  the  vagina  is  usually  a  congenital  con- 
dition and  is,  of  course,  a  barrier  to  pregnancy.  Its  association  with  the 
absence  or  imperfect  development  of  the  other  pelvic  organs  and  the 
treatment  of  the  condition  will  be  found  discussed  in  works  on  gynecology. 

Stenosis  of  the  Vagina. — The  most  important  form  of  vaginal  stenosis 
is  congenital  in  origin  and  occurs  as  a  perforated  diaphragm  stretched 
across  the  ^'agina  at  about  the  junction  of  its  upper  one-third  with 
the  lower  two-thirds.  The  first  feel  to  the  examining  fingers  is  that  of 
a  blind  vaginal  fornix,  but  careful  examination  usually  detects  a  small 
opening  in  the  diaphragm  and  above  it  a  cervix. 

When  first  found  in  labor  it  may  suggest  the  necessity  for  a  Cesarean 
section,  but  although  a  number  of  instances  of  this  condition  have 
occurred  in  the  author's  experience,  in  each  instance,  as  the  cervix  dilated 
and  allowed  the  presenting  part  to  come  down  upon  the  diaphragm,  its 
opening  dilated  rapidly,  like  a  thinned-out  cervix,  and  labor  progressed 
favorably. 

If  dystocia  arose  from  this  diaphragm,  a  small  crucial  incision  could 
be  made  in  it  and  the  opening  mechanically  dilated  with  the  elastic  bag. 

Cicatricial  stenosis  of  the  vagina  sometimes  arises  from  injuries  or 
from  extensive  inflammation  with  ulceration.  At  the  time  of  labor  the 
narrowed  canal  usually  softens  and  dilates  sufficiently  for  the  child  to 
pass,  but  if  dystocia  arises  from  it,  the  dilatation  ma}-  be  facilitated  by 
the  use  of  the  elastic  bag,  or  in  rare  instances  multiple  incisions  may  be 
advisable. 

Septa  in  the  Vagina. — In  the  same  way  that  an  arrest  in  the  process 
of  absorption  of  the  partition  between  the  canals  of  the  two  ducts  of 
Midler  may  leave  an  anteroposterior  septum  in  the  cervix,  so  the  same 
arrest  may  leave  a  double  vagina  to  a  greater  or  less  height.  As  a  rule 
the  septum  is  more  apt  to  be  present  below  and  absent  above,  near  the 
cervix.  It  may  be  only  a  narrow  band  or  it  may  be  a  partition  and  reach 
almost,  if  not  quite,  to  the  cervix.  The  septa  are  usually  anteroposterior, 
but  occasionally  are  transverse  or  oblique.  It  is  not  often  that  vaginal 
septa  cause  dystocia  as,  if  it  is  a  double  vagina,  nature  usually  selects 
one-half  and  sufficiently  dilates  it,  or  if  it  is  only  a  narrow  band,  it  is 
usually  slipped  to  one  side  by  nature  or  can  easily  be  so  slipped  or  ligated 
and  cut  by.  the  obstetrician.  These  bands  are  not  very  vascular.  One 
case  in  the  author's  experience  proved  of  marked  interest.  A  patient 
with  a  vaginal  septum  reaching  nearly  to  the  cervix  was  in  labor  with  a 
breech  presentation.  After  the  rupture  of  the  membranes  one  foot  and 
a  loop  of  cord  came  dowai  to  the  vulva  in  one  half-vagina  and  the 
other  foot  in  the  other  half-\agina.  Rapid  incision  of  the  whole 
vaginal  septum  saved  the  life  of  the  child. 


ANOMALIES  OF  SOFT  PARTS  OF  PARTURIENT  CANAL       647 

N  i^n  annoying  result  of  labor  in  connection  with  a  double  vagina  has 
occurred  twice  in  the  author's  experience.  The  woman  after  getting  up 
from  her  confinement  and  going  about  complained  of  the  sagging  and 
protrusion  of  the  relaxed  vaginal  septum,  causing  annoyance  as  she 
walked.  Relief  was  given  by  excision  of  the  remains  of  the  septum  in  one 
case  and  excision  of  the  complete  septum  with  a  Hegar's  perineorrhaphy 
in  the  other. 

Septa  will  occasionally  be  found  in  the  vagina  as  a  result  of  lacerations 
and  the  miion  of  raw  surfaces  not  anatomically  belongmg  together. 
Thus  a  band  may  stretch  between  cervix  and  vagina  or  across  the 
vagina,  etc.    These  have  little  importance  in  labor. 

A  double  vagina,  with  the  septum  extending  the  whole  length  of  the 
vagina,  accompanied  by  a  double  uterus  occasionally  leads  to  an  amusing 
confusion  in  diagnosis.  Different  members  of  the  house  staff  at  the  Sloane 
Hospital  once  examined  such  a  case  and  while  one  man  reported  the  cervix 
almost  completely  dilated,  the  other  reported  no  dilatation.  One  had 
examined  one  vagina,  the  other,  the  other  one. 

Tumors  in  the  Vagina. — Cysts,  fibromata,  malignant  masses  and  hema- 
tomata  are  the  most  common  forms  of  vaginal  tumor  causing  dystocia. 

If  large  enough  to  seriously  obstruct  the  canal  these  growths  should 
if  possible  be  removed.  In  hematomata  the  best  treatment  consists  in 
incision  of  the  tumor,  turning  out  the  clots  and  packing  with  sufficient 
gauze  to  control  the  hemorrhage. 

If  the  mass  cannot  be  removed,  as  in  cases  of  inoperable  carcinoma. 
Cesarean  section  may  be  the  best  method  of  delivery. 

Rigid  Vulvar  Orifice. — ^In  some  elderly  primigravidse,  especially  those 
who  on  accomit  of  vaginismus,  or  for  some  other  reason  have  had  only 
infrequent  intercourse,  also  in  athletic  women  who  through  horseback 
riding  or  other  forms  of  exercise  have  highly  developed  the  muscles  of 
the  pelvic  floor,  the  vulvar  orifice  is  so  rigid  as  to  cause  distinct  dystocia 
from  tardy  dilatation. 

A  rigid  vulvar  orifice  sometimes  also  results  from  cicatrices  arising 
from  traumatism  of  the  vulva,  or  from  extensive  inflammation  with 
ulceration. 

It  often  happens  in  cases  of  rigid  vulvar  orifice  that  dilatation  needs  to 
be  facilitated,  both  to  lessen  the  suffering  of  the  woman  and  conserve  her 
strength,  and  also  in  the  interest  of  the  child  whose  welfare,  as  shown  by 
the  fetal  heart  sounds,  would  be  endangered  by  a  longer  continuation  of 
pressure.  The  dilatation  in  such  cases  may  weU  be  facilitated  by  gradual 
stretching  with  gloved  fingers  or  by  the  use  of  a  large-sized  elastic  bag. 

Hematoma  of  the  Vulva. — Not  infrequently  as  a  result  of  straining 
during  the  labor  or  of  traumatism  in  efforts  at  delivery,  a  hematoma  of 
the  vulva  is  formed  which  narrows  the  vulvar  orifice  and  so  causes 
dystocia. 

The  treatment,  as  in  hematoma  of  the  vagina,  consists  in  incision,  turn- 
ing out  the  clots  and  packing  with  sufficient  gauze  to  control  the  bleeding. 

Edema  of  the  Vulva. — This  condition  (see  Fig.  382)  may  be  the  result 
of  general  or  local  causes.    It  may  arise  as  a  part  of  a  general  edema 


(')4S        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

due  to  nephritis,  or  as  a  result  of  i)ressure  of  the  eliild,  eitlier  (hiring 
preguaney  or  during  the  eourse  of  a  long,  dry  labor.  Although  edema 
of  the  vulva  does  uot  usually-  eause  marked  dystocia,  it  does  greatly 
predispose  to  lacerations  of  the  vulva  and  perineum  and  in  some  cases 
so  lowers  the  vitality  of  the  tissue  that  sloughing  results. 

Edema  of  the  vuha  occurring  during  pregnancy  will  often  subside 
if  the  patient  is  put  to  bed  and  kept  oft"  her  feet  for  a  few  days. 

Treatment. — Pricking  the  edematous  tissue  witli  sterile  needles  and 
covering  the  parts  with  a  sterile  dressing  will  often  rapidly  relieve  the 
condition. 


Fig.  382. — Edema  of  the  \-ulva. 


/ 


ANOMALIES  OF  THE  HARD  PARTS  OF  THE  PARTURIENT  CANAL. 

The  most  serious  forms  of  abnormal  labor  are  associated  with  anomalies 
of  the  hard  parts  and  will  now  be  considered  under  the  head  of 


Deformities  of  the  Pelvis. 

A  pelvis  is  considered  deformed  when  it  is  so  abnormal  in  either  size, 
shape  or  articulation  as  to  interfere  with  the  mechanism  or  progress 
of  normal  labor.  This  definition  does  not  exclude  the  possil)ility  of  un- 
aided delivery,  for  many  cases  of  markedly  deformed  pelvis  have  easy 
deliveries,  either  because  the  available  birth  canal  is  ample  in  size,  or 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      649 

because  the  child  is  small.  In  1770  cases  of  deformed  pelvis  at  the 
Sloane  Hospital  815,  or  about  4(3  per  cent.,  delivered  themselves 
normally  at  term. 

Frequency. — Since  the  time  of  Heinrich  von  Deventer,^  who  in  1701  first 
described  deformities  of  the  nelvis  from  the  obstetrical  standpoint,  our 
knowledge  of  this  subject  has  gradually  developed,  but  it  is  only  in  recent 
years,  since  routine  pelvimetry  became  the  rule  in  the  care  of  pregnant 
women,  that  an  accurate  idea  as  to  the  frequency  and  variety  of  pelvic 
deformity  has  been  obtained. 

The  frequency  of  pelvic  deformity  varies  greatly  in  different  countries 
and  in  different  races  in  the  same  country. 

At  the  Sloane  Hospital  for  Women,  in  20,000  consecutive  deliveries 
there  were  1770  cases  with  deformed  pelvis,  or  8.8  per  cent.,  but  as  stated 
above,  of  these  1770  cases,  815,  or  46  per  cent,  delivered  themselves 
normally  at  term;  and,  moreover,  in  the  remaining  955,  371,  or  20  per 
cent.,  were  delivered  prematurely,  leaving  only  584,  or  33  per  cent.,  of  the 
deformed  pelves  which  caused  d}' stocia  at  term.  At  the  Sloane  Hospital 
justomajor  pelves  are  not  classified  as  deformed  pelves,  or  the  frequency 
of  8.8  per  cent,  would  doubtless  be  increased.  At  the  Sloane  Hospital 
rachitic  pelves  are  not  classified  by  themselves  but  are  included  with 
the  simple  flat,  the  justominor  and  the  justominor  flat,  hence  the  fre- 
quency of  each  of  these  varieties  is  doubtless  somewhat  increased. 

It  must  be  understood  that  in  assigning  a  given  case  to  the  class  of 
deformed  pelves,  trouble  will  arise  when  the  departure  from  the  normal 
measurements  is  slight  and  the  labor  presents  little  difficulty. 

There  will  always  be  a  large  number  of  these  border-line  cases  which 
one  observer  would  place  on  one  side  of  the  line  and  another  on  the  other. 

In  studying  abnormal  pelves  we  must  constantly  have  before  us  the 
normal  pelvis  and  its  measurements,  and  carefully  note  any  marked 
departure  from  this  normal. 

For  all  practical  purposes  the  normal  pelvic  measurements  may  be 
regarded  as  follows: 

EXTERNAL  MEASUREMENTS. 

DIAMETERS    OF    THE    INLET. 

Interspinous 26  cm. 

Intercristal 28  cm. 

Left  oblique 22  cm. 

Right  oblique 22+  cm. 

External  conjugate 20  cm. 

DIAMETERS    OF    THE    OUTLET. 

Anteroposterior 9.50  cm.-ll  ..50  cm. 

Transverse 11  cm. 

INTERNAL  MEASUREMENTS. 

DIAMETERS    OF    THE    BRIM. 

Anteroposterior  (true  conjugate) 11  cm. 

Oblique 12  cm. 

Transverse 13  cm. 

DIAMETfeRS    OF    THE    CAVITY. 

Each 12  cm. 

^  Operationes  chirurgicffi  no^'nm  lumen  exhibentes  obstetricanibus,  1701. 


650        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

Varieties  of  Deformed  Pelvis. — Tn  his  teaching  the  autlior  has  adopted 
the  following  classification,  based  on  the  etiology  of  the  condition  and 
similar  to  that  of  Schauta:^ 

1.  Anomalies  resulting  from  faulty  development: 

(a)  Simple  fiat,  non-rachitic  pelvis. 

(6)  Generally,  equally  contracted  (justominor)  pelvis. 

(c)  Generally,  contracted  flat  (justominor  flat)  pelvis. 

(d)  Funnel-shaped  or  masculine  pelvis. 

(e)  Obliquely  contracted  (Naegele)  pelvis. 

(/)  Double  obliquely  contracted  (Robert)  pelvis. 
(g)  Generally,  equally  enlarged  (justomajor)  pelvis.^ 
(h)  Split  pelvis. 

2.  Anomalies  resulting  from  disease  of  the  pelvic  bones  or  traumatism: 

(a)  Rachitic  pelvis. 

(6)  Osteomalacic  pelvis. 

(c)  New  growths. 

(d)  Caries,  necrosis,  atrophy. 

(e)  Fracture. 

3.  Anomalies  in  the  articulations  of  the  pelvic  bones: 

(a)  Abnormally  firm  union  (synostosis). 

1.  Of  the  symphysis. 

2.  Of  one  or  both  sacro-iliac  joints. 

3.  Of  the  sacrum  with  the  coccyx. 
(h)  Abnormally  loose  union. 

4.  Anomalies  resulting  from  diseases  of  the  superimposed  skeleton: 

(a)  Spondylolisthesis. 

(b)  Kyphosis. 

(c)  Scoliosis. 

(d)  Kyphoscoliosis. 

(e)  Lordosis. 

5.  Anomalies  resulting  from  abnormalities  of  the  subjacent  skeleton: 

(a)  Coxitis. 

(b)  Dislocation  of  the  femur  or  femora. 

(c)  Absence  or  deformity  of  one  or  both  lower  extremities. 

Deformities  of  the  Pelvis  Resulting  from  Faulty 
Development. 

In  studying  the  development  of  the  normal  pelvis  it  is  seen  that  its 
peculiar  shape  is  the  result  of  a  number  of  different  forces,  viz.: 
(a)  The  growth  of  the  individual  pelvic  bones. 

(6)  Traction  exerted  on  these  growing  bones  by  muscles  and  liga- 
ments. 

(c)  Pressure  downward  upon  these  growing  bones  by  the  superim- 

posed trunk. 

(d)  Pressure  upward  througli  the  fem'ora. 

1  Die  Beckenanomalien,  Miiller's  handbuch  der  Geb.,  1889,  p.  IL 

2  At  the  Sloane  Hospital  justomajor  pelves  are  not  included  among  deformed  pelves. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL     651 

The  final  shape  of  the  pelvis  is  the  resultant  of  these  different  forces. 
If  any  of  these,  forces  are  deficient  or  in  excess  the  normal  equilibrium  is 
disturbed  and  the  pelvis  fails  to  assume  its  normal  shape  and  size. 

Even  if  the  forces  of  traction,  pressure  and  counter-pressure  are  nor- 
mal, if  they  are  brought  to  bear  upon  bones  smaller  than  normal,  even 
though  healthy,  deformity  may  result.  The  same  forces  acting  upon  bones 
softened  by  disease  may  cause  even  greater  deformity. 

Viewed  clinically,  pelves  may  be  contracted  in  the  following  diameters: 
(a)  The  anteroposterior. 
(6)  The  oblique, 
(c)  The  transverse. 
{d)  All  diameters. 

The  Simple  Flat,  Non-rachitic  Pelvis. — ^In  this  variety  of  pehdc 
deformity  there  is  a  shortening  of  the  anteroposterior  diameters  of  the 
pelvic  canal  while  the  transverse  diameters  remain  practically  normal. 

Frequency.— This  is  one  of  the  most  common  forms  of  pelvic  deformity; 
Michaelis^  finding  it  in  43  per  cent,  of  the  72  cases  of  contracted  pelvis 
described  by  him. 

At  the  Sloane  Hospital,  among  the  1770  deformed  pelves  occurring 
in  20,000  consecutive  deliveries,  the  simple  flat  pelvis  was  found  in  1129, 
or  63.7  per  cent.  Of  the  1170  deformed  pelves  among  the  whites  there 
were  869  of  the  simple  flat  variety,  or  75  per  cent.,  while  of  the  600 
among  the  blacks  there  were  280,  or  43.2  per  cent. 

J.W.Williams  of  Baltimore,  found  it  in  32  per  cent,  of  ah  contracted 
pelves  in  white  women  as  compared  with  2  per  cent,  in  colored. 

It  is  found  among  the  upper  classes  as  well  as  the  lower;  in  the  well- 
nourished  and  apparently  well-developed  as  also  in  those  subjected 
to  privation.  But  little  is  known  of  its  etiology,  and  the  lifting  and 
carrying  heavy  weights  which  formerly  were  emphasized  as  causative 
factors  now  receive  little  consideration  in  this  country.  It  seems  to  be 
a  congenital  condition,  as  not  infrequently  a  fetus  or  child  at  birth  will 
present  a  pelvis  of  this  shape.  In  some  families  it  seems  to  be  hereditary, 
and  mother  and  daughter  have  pelves  of  similar  contraction. 

Characteristics.- — In  the  simple  flat  pelvis  the  sacrum  is  set  forward 
as  a  whole  without  rotation  on  its  transverse  axis,  as  occurs  in  the  flat 
rachitic  pelvis.  This  shortens  the  conjugate  diameter  throughout  the 
whole  length  of  the  pelvic  canal,  leaving  the  other  diameters  undisturbed. 
Although  the  sacrum  is  set  forward-  as  a  whole  the  practical  obstruction 
to  labor  is  most  marked  at  the  superior  strait.  Not  infrequently  in  this 
type  of  pelvic  deformity  there  is  a  double  promontory  caused  by  the 
projection  of  one  of  the  lower  intervertebral  articulations  of  the  sacrum 
(see  Fig.  383  j.  In  this  case  the  conjugate  should  be  measured  from  the 
lower  promontory.  The  amount  of  contraction  in  a  simple  flat  pelvis  is 
moderate,  seldom  reaching  2  cm. 

Diagnosis. — Unless  there  is  the  history  of  a  previous  difficult  labor, 
the  simple  flat  pelvis  is  easily  overlooked,  as  it  may  occur  in  those  pre- 

1  Das  enge  Becken,  Leipzig,  ISol. 


052        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 


senting  the  picture  of  perfect  health  aiul  (levelopmeut.  It  is  only  by 
the  practise  of  careful  pehimetrv  as  a  routine  procedure  that  this  error 
is  avoided.  IIo\ve\er,  if  the  pelvis  of  each  obstetric  patient  is  carefully 
measured,  the  diagncsis  of  a  simple  flat  pehis  is  usually  made  with  ease. 
The  external  conjugate  is  found  shortened,  perhaps  measures.  18  cm. 
instead  of  the  normal  20  cm.,  and  on  internal  examination  the  sacrum 
from  promontory  to  coccyx  is  more  readily  felt  than  normal,  while  the 
lateral  walls  feel  at  their  usual  distance.  The  pelvis  is  a-  symme- 
trical one  and  therefore  does  not  interfere  with  locomotion.  When  dis- 
cussing pehimetry  attention  was  called  to  the  fact  that  occasionally  the 

external  conjugate  gives  little  idea 
of  the  available  internal  conjugate. 
So  long  as  a  simple  flat  pelvis 
is  occasionally  found  in  well-nour- 
ished patients' with  otherwise  large 
pelves,  and  so  long  as  the  external 
conjugate  occasionally  fails  to  indi- 
cate an  internal  shortening,  sur- 
prises are  bound  at  times  to  come 
unless  the  promontory  of  the  sac- 
rum is  always  felt  for  with  the 
^'aginal  fingers.  Even  then,  in 
some  pelves  the  promontory  may 
be  so  high  up  that  an  undue 
})rominence  of  it  cannot  be  felt, 
especially  in  the  latter  part  of 
pregnancy  when  a  thorough  ex- 
amination is  more  difficult. 

The  simple  fiat  peh'is  may  be 
confused  with  aflat  rachitic  pelvis, 
but  as  in  diagnosing  the  justo- 
minor  pelvis,  so  here  the  rachitic 
pelvis  is  distinguished  by  the 
disturbance  of  the  normal  rela- 
tions between  anterior  superior  spines  and  crests.  j_n  the  rachitic  peli:is 
the  interspinous  diameter  is  equal  to,  or  greater  than,  the  intercristah 

Pregnancy  and  Labor  in  the  Simple  Flat  Pelvis. — On  account  of  the 
anteroposterior  contraction  at  the  brim  of  the  pelvis  there  is  often  a 
failure  of  the  presenting  part  to_eiiter_the  brim  during  the  last  weeks  of 
•  gestation,,  and  consequently  abnormal  prominence  of  the  abdomen,  some 
degree  of  pendulous  abdomen,  and  various  malpresentations  are  com- 
mon. As  the  presenting  part  does  not  readily  enter  and  fill  the  brim 
of  the  pelvis,  p^olnpse  of  the  coid  is  a  frequent  complication. 

The  first  stage  of  labor  is  usualh'  protracted  both  on  account  of  the 

<^slojmess  of  thejiead  ijDLjeugagiiLg_and  the  slowness  of  tji£,  cervix-JB-dilat- 

ing.    As  the  head  does  not  readily  descend  to  press  upon  the  cervix  its 

dilatation  is  accomplished  by  a  retraction  of  the  cervix  over  the  head 

aided  by  the  projecting  bag  of  waters,  if  the  membranes  are  unruptured. 


Fig.  383. — Simple  flat  pelvis  with  double 
IJi'omontory.      (Buinni.) 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      653 

Often,  however,  the  membranes  rupture  early  and  this  still  more  retards 
the  dilatation  of  the  cervix.  As  a  rule  the  head  enters  the  pelvis  trans- 
versely and  partly  extended,  so  that  the  anterior  fontanelle  may  be 
easily  felt  instead  of  being  high  up  and  out  of  reach,  as  in  the  justominor 
pelvis.  There  is  an  exaggeration  of  the  lateral  obliquity,  the  sagittal 
suture  usually  approaching  the  sacral  promontory. 

That  part  of  the  fetal  head  encountering  the  most  resistance  is  the 
last  to  enter,  hence  usually  the  anterior  parietal  bone  enters  first  and 
overlaps  the  posterior.  On  the  child's  head  after  birth  can  often  be 
found  a  depression  where  the  posterior  parietal  bone  rested  against  the 
promontory,  this  depression  lying  usually  near  the  sagittal  suture  between 
the  anterior  fontanelle  and  the  parietal  eminence.  Occasionally  the 
lateral  obliquity  takes  the  opposite  direction;  the  anterior  parietal  bone 
impinging  on  the  pubes  and  the  posterior  parietal  bone  being  the  first  to 
enter  the  pelvis. 

Although  the  anteroposterior  diameter  of  the  pelvic  canal  is  short- 
ened throughout,  it  is  at  the  brim  that  thejd£La^iiLJJi£,labQr-ia-JiLo^t 
marked  and  usually  after  the  head  has  passed  the  narrowing  at  the  brim 
the  labor  progresses  favorably  and  often  unaided  to  its  termination.  Not 
infrequently,  however,  so  much  time  and  effort  has  been  consumed  in 
securing  engagement  of  the  head  that  the  natural  forces  are  exhausted 
and  the  delivery  has  to  be  completed  by  the  forceps  or  version. 

The  Generally,  Equally  Contracted  or  Justominor  Pelvis. — Frequsncy. 
— This  is  one  of  the  most  frequent  varieties  of  deformed  pelvis  found  in 
large  cities  like  New  York,  especially  in  girls,  such  as  shop-girls,  who 
have  worked  hard  with  insufficient  fresh  air  and  nourishment.  At  the 
Sloane  Hospital  for  Women  it  occurred  as  follows:  In  20,000  consecu- 
tive deliveries  there  were  found  1770  deformed  pelves,  of  which  224,  or  12 
per  cent.,  were  justominor.  Of  the  1770  deformed  pelves,  1170  occurred 
among  whites  and  600  among  blacks.  Of  the  1170  among  the  whites 
only  85,  or  7.2  per  cent.,  were  justominor,  while  of  the  600  among  the 
blacks  139,  or  23  per  cent.,  were  justominor.  Edgar,^  of  New  York,  found 
this  deformity  in  2.5  per  cent.,  of  all  his  cases.  Williams,^  of  Baltimore, 
found  it  in  one-third  of  the  contracted  pelves  in  white  women  and  two- 
thirds  of  those  occurring  in  black  women.  Miiller,''  of  Germany,  found  it 
in  37  per  cent,  of  his  cases  of  contracted  pelvis,  and  Richelet,^  of  France, 
in  28  per  cent. 

It  is  the  pelvis  to  be  expected  in  small  women,  but  occasionally  it  is 
found  in  large  women  who  are  apparently  well  developed  and  of  per- 
fect stature.  It  is  a  symmetrical  pelvis,  hence  does  not  interfere  with 
walking  or  other  exercise  and,  save  for  careful,  routine  pelvimetry,  would 
be  likely  to  be  overlooked  until  the  time  of  labor. 

Characteristics. — In  the  justominor  pelvis  all  the  diameters  are  re- 
duced, but  so  reduced  as  to  maintain  the  symmetry  of  the  pelvis  and 

1  The  Practice  of  Obstetrics,  1907.  2  Obstetrics,  1908. 

'  Zur  Frequenz  u.  Aetiologie  des  Allg.  verengten  Beckens,  Archiv  f.  Gyn.,  1880,  xvi, 
155-173. 

^  Du  Bassin  generalement  retreci,  etc..  These  de  Paris,  1896. 


654        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

yet  the  shortening  of  the  different  diameters  may  not  be  actually  uni- 
form, as  the  reduction  in  the  size  of  the  brim  may  be  a  little  less  than 
that  of  the  outlet,  or  vice  versa.  The  sacrum  in  a  justominor  pelvis  is 
set  a  little  higher  and  farther  back  than  normal  and  the  promontory  is 
not  tilted  forward.  This  explains  why  in  ])elvimetry  in  this  type  of  pelvis 
the  external  conjugate  is  often  found  relatively  longer,  and  therefore 
more  nearly  normal,  than  the  other  diameters.  It  also  explains  why,  in 
taking  the  diagonal  conjugate  in  a  justominor  pelvis,  it  is  harder  to 
reach  the  promontory  of  the  sacrum  than  would  be  expected  from  the 
size  of  the  pelvis.  The  posterosuperior  iliac  spines  are  relatively  farther 
apart  than  normal  on  account  of  the  retroplacement  of  the  sacrum,  and 
the  transverse  concavity  of  the  sacrum  is  often  found  increased. 

The  bones  of  the  pelvis  as  a  whole  are  usually,  but  by  no  means  always, 
a  little  lighter  than  normal.  The  shortening  of  the  anteroposterior 
diameter  in  a  justominor  pelvis  usually  varies  between  1  and  2  cm.  and 
seldom  gives  a  conjugate  of  less  than  9  cm. 

Diagnosis. — As  already  seen,  the  diagnosis  of  a  justominor  pelvis  prior 
to  labor  is  only  made  by  careful  pelvimetry. 

As  the  external  conjugate  is  less  reduced  than  the  other  measurements 
taken  in  external  peh'imetry,  it  is  to  the  oblique  diameters  that  we  look 
for  our  diagnosis  of  a  justominor  pelvis.  The  oblique  diameters  of  a 
normal  pelvis  are  regarded  as  approximately  22  cm.,  the  right  oblique 
being  a  trifle  longer  than  the  left.  At  the  Sloane  Hospital,  although 
admitting  that  the  classification  is  more  or  less  arbitrary,  it  is  the 
author's  custom  to  allow  a  variation  of  approximately  2  cm.  on  either 
side  of  this  normal  average  of  22  cm.  for  the  oblique  diameters  before 
transferring  the  case  from  the  class  of  normal  to  that  of  abnormal  pelves. 

Thus,  between  the  measurements  of  20  cm.  and  24  cm.  in  the  oblique 
diameters,  other  things  being  equal,  the  pehis  may  be  considered  nor- 
mal, with  the  variation  allowed  to  different  individuals,  the  same 
as  is  allowed  in  the  sizes  of  heads,  hands  and  feet  which  may  vary  greatlj' 
and  yet  be  considered  normal. 

On  the  other  hand,  a  symmetrical,  uniformly  contracted  pelvis  whose 
oblique  diameters  measure  20  cm.  or  less  is  called  a  justominor  pelvis. 

Furthermore,  as  will  be  studied  later,  a  symmetrical  pelvis  uniformly 
enlarged,  whose  oblique  diameters  measure  24  cm.  or  over,  is  called  a 
justomajor  pelvis. 

The  justominor  pelvis  might  easily  be  confused  with  a  rachitic  pelvis, 
but  is  differentiated  from  it  by  one  characteristic  feature,  viz.,  in  the 
justominor  pelvis  the  normal  relation  between  the  interspinous  and 
intercristal  diameters  is  maintained,  and  the  latter  is  greater  than  the 
former.  In  the  rachitic  pelvis,  however,  as  will  be  studied  later,  this 
relation  is  disturbed,  and  the  interspinous  diameter  is  equal  to,  or  greater 
than,  the  intercristal. 

Labor  in  a  Generally  Contracted  (Justominor)  Pelvis. — As  all  the  diam- 
eters of  the  pelvis  are  contracted,  it  is  readily  seen  that  with  a  normal- 
sized  child  the  labor  is  likely  to  be  prolonged. 

The  fetal  head  can  onlv  enter  the  brim  in  marked  flexion  and  this 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      655 

flexion  with  additional  molding  must  continue  until  the  pelvic  floor 
is  reached.  This  means  that  the  posterior  fontanelle  will,  as  a  rule, 
be  easily  felt,  while  the  anterior  fontanelle  will  be  high  up,  out  of  reach. 

The  posterior  fontanelle,  moreover,  will  be  small  and  show  the  over- 
lapping of  the  parietal  bones.  The  caput  usually  becomes  marked 
before  the  labor  is  completed.  Another  reason  for  the  prolongation  of 
the  labor,  aside  from  the  reduction  in  size  of  the  canal  throughout  its 
length  is  that,  associated  with  this  increase  in  the  resistant  forces,  there 
is  often  a  decrease  in  the  expulsive  force  in  the  uterus  and  abdominal  wall 
on  account  of  poor  physical  development  of  the  individual. 

In  the  justominor  pelvis,  as  stated  above,  the  contraction  in  the 
different  diameters  continues  from  brim  to  outlet,  hence  the  difficulties  in 
the  labor  and  causes  of  its  prolongation  are  not  passed  when  the  head 
reaches  the  cavity  of  the  pelvis,  as  often  happens  in  the  case  of  a  simple 
flat  pelvis  just  described. 

Generally  Contracted,  Flat  (Non-rachitic)  Pelvis. — This  type  of  pelvis 
combines  the  features  of  the  two  preceding:  the  justominor  and  the 
simple  flat  pelvis,  i.  e.,  all  the  diameters  are  below  normal,  but  the  con- 
jugate is  relatively  less  than  any  of  the  others.  This  pelvis  has  many 
of  the  features  of  the  rachitic  but  differs  from  it  in  the  following  par- 
ticulars : 

1.  The  anterior  half  of  the  pelvis  is  not  markedly  broadened,  i.  e., 
the  normal  relation  between  the  interspinous  and  intercristal  diameters 
is  not  disturbed. 

2.  The  sacrum  is  relatively  retroplaced  rather  than  anteplaced.  The 
sacrum  is  small  and  is  considerably  higher  than  in  the  normal  pelvis. 
Although  nearer  the  symphysis  than  in  the  normal  pelvis,  it  is  placed 
farther  back  between  the  innominate  bones  than  normal. 

According  to  Litzman,  the  closer  proximity  of  the  sacrum  to  the  sym- 
physis and  resulting  flattening  of  the  pelvis  is  due  to  a  shortening  of 
the  innominate  bones.  The  promontory  is  high  and  hence  the  diagonal 
conjugate  is  relatively  increased  and  the  promontory  is  not  prominent. 

Frequency. — This  type  of  pelvis  is  met  with  quite  frequently  in  New 
York.  In  the  1770  cases  of  deformed  pelvis  occurring  in  20,000  consecu- 
tive deliveries  at  the  Sloane  Hospital,  354,  or  20  per  cent.,  were  justo- 
minor flat.  A.mong  the  1170  whites  in  this  series  there  were  148,  or  12.6 
per  cent.,  justominor  flat  pelves,  while  in  the  600  blacks  there  were  206, 
or  34.3  per  cent. 

It  is  a  congenital  deformity  due  to  some  hereditary  influence  or  an 
arrested  development  in  fetal  or  infant  life.  It  is  claimed  by  some  that 
it  is  due  to  premature  walking  or  long  standing  in  early  childhood. 

Diagnosis. — ^This  can  only  be  made  by  careful  pelvimetry,  both  exter- 
nal and  internal.  The  patient  may  appear  perfectly  well  and  strong  and 
know  of  no  reason  why  she  should  not  bear  children  normally  and  easily, 
but  accurate  pelvimetry  will  show  that  the  diameters  of  the  pelvis  are 
all  reduced,  and  the  internal  conjugate  more  than  the  others. 

The  ease  with  which  the  lateral  pelvic  walls  can  be  palpated  is  also 
worthy  of  note  and  is  of  value  in  verifying  the  diagnosis. 


V 


656        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

Labor  in  the  Generally  Contracted  Flat  Pelvis.- — It  can  easily  be  seen 
that  labor  in  this  type  of  pehis  combines  the  difficulties  of  the  two 
preceding.  It  is  more  difficult  than  in  the  justominor  pelvis  because 
it  is  flat,  and  it  is  more  difficult  than  in  the  simple  flat  pelvis  because 
it  is  justominor,  i.  e.,  the  compensating  room  in  the  sides  of  the  pelvic 
cavity  usually  present  in  the  simple  flat  pelvis  is  absent  on  account  of 
the  shortening  of  the  oblique  diameters.  The  entire  pelvis  is  below 
normal  in  size.    * 

The  Narrow,  Funnel-shaped  Pelvis. — This  type  of  pelvis  is  contracted 
at  the  outlet,  either  trans\'ersely  or  in  both  its  transverse  and  antero- 
posterior diameters.  While  most  marked  examples  of  the  funnel-shaped 
pehis  are  found  associated  with  a  lumbar  kyphosis,  which  will  be  dis- 
cussed later,  a  narrow,  funnel-shaped  pelvis  is  occasionally  met  with,  due 
to  faulty  development  without  associated  abnormalities  in  the  spinal 
column.  The  depth  of  the  pelvis  is  greater  than  normal  on  account  of 
the  increased  length  of  the  sacrum,  greater  dej^th  of  the  lateral  walls, 
and  greater  height  of  the  symphysis. 

The  sacrum  is  narrow,  straighter  than  normal,  and  placed  far  back 
between  the  ilia. 

Frequency. — Although  formerly  considered  very  rare,  since  systematic 
examination  of  the  outlet  of  the  pelvis  has  become  a  routine  procedure 
in  many  hospitals,  it  is  found  quite  frequently.  Schauta  estimated  5.9 
per  cent,  of  funnel-shaped  pelves  in  5000  cases,  and  Williams,^  in  a  con- 
secutive series  of  2215  full-term  labors,  found  135  typical  funnel  pelves, 
or  an  occurrence  of  fi.l  per  cent. 

In  the  series  of  2215  labors  reported  by  Williams,  there  were  1313 
white  and  902  black  women,  and  of  these  135  funnel  pelves  77,  or  5.87  per 
cent.,  occurred  in  the  white,  as  compared  with  58,  or  6.43  per  cent., 
occurring  in  the  black  women. 

In  this  same  series  of  1313  white  women,  in  addition  to  the  77  funnel 
pelves,  he  found  98  examples  of  the  difl'erent  ^'arieties  of  contraction  of 
the  pelvic  outlet,  as  compared  with  58  funnel  pelves  and  312  outlet 
contractions  in  the  902  black  women. 

This  would  indicate  that  in  the  white  race  the  funnel  pelvis  is  of  rela- 
tively greater  frequency  than  in  the  colored,  constituting  44  per  cent, 
of  the  abnormal  pelves  in  this  series  of  1313  white  women,  as  compared 
with  15.23  per  cent,  of  the  abnormal  pelves  in  the  902  black  women. 

Etiology. — ^The  exact  cause  of  this  variety  of  deformity  is  unknown. 
It  has  usually  been  assigned  to  a  continuation  of  the  infantile  type,  and 
has  often  been  found  in  those  who  on  account  of  anterior  poliomyelitis 
or  other  reasons  have  been  unable  to  walk. 

Williams  believes  that  the  great  majority  of  outlet  contractions  are 
associated  with  assimilation  of  the  last  lumbar  vertebra  with  the  sacrum, 
causing  the  sacrum  to  consist  of  six  vertebrse  instead  of  five,  and  in  a 
number  of  his  cases  he  has  been  able  to  palpate  six  sacral  vertebrae 
through  the  vagina. 

■  The  Funtiol  Pelvis,  Amor.  Jour.  Obst.,  .July,  1011,  Ixiv,  No.  403,  p.  lOfi. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      657 

Diagnosis, — This  is  made  by  a  comparison  of  the  measurements  of  the 
outlet  with  those  of  the  inlet  of  the  pelvis.  Whether  the  inlet  is  normal, 
above  normal  or  abnormally  small,  the  outlet  is  always  smaller  than 
would  naturally  correspond  with  these  measurements.  Furthermore, 
on  vaginal  examination  and  palpation  the  pelvic  walls  are  felt  to  con- 
verge toward  the  outlet  and  the  pubic  arch  feels  narrow.  To  Williams, 
of  Baltimore,  the  profession  is  indebted  for  emphasizing  the  importance 
of  carefully  measuring,  or  at  any  rate  palpating  the  outlet  of  the  pelvis 
and  thus  avoiding  the  serious  embarrassment  of  meeting  unexpectedly 
with  serious  dystocia  at  the  outlet  of  a  pelvis  whose  inlet  seemed  normal. 

Practically,  a  pelvis  may  be  considered  a  funnel  pelvis  when  either 
the  transverse  or  the  anteroposterior  diameters  of  the  outlet  are  reduced, 
the  former  from  11  cm.  to  8  cm.  or  less  and  the  latter  from  11.50  cm.  to 
9  cm.  or  less.  Ankylosis  of  the  sacrococcygeal  joint  with  coccyx  forward 
presents  a  similar  condition,  but  this  is  usually  overcome  by  fracture 
during  delivery. 

Labor  in  the  Narrow,  Funnel-shaped  Pelvis.-^As  would  naturally  be 
supposed,  the  difficulties  in  the  labor  occur  not  at  the  inlet,  which  may 
be  as  large  as  or  even  larger  than  normal,  but  at  the  outlet  of  the 
pelvis. 

Here  malpositions  of  the  head  are  common,  such  as  posterior  positions 
of  the  occiput;  oblique  or  transverse  positions  of  the  head,  and  imperfect 
flexion.  Moreover,  the  expulsive  forces  are  often  deficient  at  this  critical 
time,  the  greater  part  of  the  fetus  lying  in  the  lower  uterine  segment 
and  the  vagina,  while  the  upper  uterine  segment  is  contracted,  retracted, 
empty,  and  powerless. 

The  length  of  the  anteroposterior  diameter  of  the  outlet  of  the  pelvis 
is  by  no  means  a  criterion  of  the  space  available  for  the  passage  of  the 
fetal  head,  as  the  pubic  arch  is  often  so  narrow  that  the  head  cannot 
enter  it.  In  fact  in  many  cases  the  only  space  available  for  the  passage 
of  the  fetal  head  is  that  between  the  tuberosities  of  the  ischia  and  the 
coccyx,  this  latter  of  course  allowing  some  retroplacement. 

Klein,^  in- 1896,  pointed  out  the  fact  that  the  prognosis  of  labor  depends 
not  so  much  upon  the  absolute  size  of  the  transverse  diameter  of  the 
outlet  as  upon  its  relation  to  the  distance  between  the  centre  of  the 
transverse  diameter  and  the  anterior  surface  of  the  tip  of  the  sacrum 
(not  coccyx).  This  distance  he  calls  the  "posterior  sagittal  diameter" 
(see  Fig.  384),  and  gives  as  the  normal  diameters  of  the  pelvic  outlet: 
transverse,  11  cm.;  anterior  sagittal,  6  cm.;  posterior  sagittal,  9.95  cm. 
Although  a  transverse  diameter  of  8  cm.  at  the  pelvic  outlet  may  well 
be  looked  upon  as  a  danger  signal,  still  it  by  no  means  follows  that 
this  diameter  will  be  associated  wdth  marked  dystocia,  as  the  posterior 
sagittal  diameter  may  give  ample  room  for  the  fetal  head,  as  indicated 
in  Fig.  385.  AATiile  a  wider  transverse  diameter  with  a  shorter  posterior 
sagittal  (see  Fig.  386)  may  require  Cesarean  section  for  delivery  of  a 
living  child.    This  crowding  of  the  fetal  head  toward  the  posterior  part 

1  Die  Geburtshlilfliche  Bedeutung  der  verengerungen  des  Beckenausgangs.     Volkmann's 
Samml.  klin.  Vortrage,  1896,  N.  F.,  No.  169. 
42 


658 


ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 


of  the  pelvic  outlet  in  a  funnel  pelvis  tends  to  severe  lacerations  of  the 
pelvic  floor,  even  if  delivery  through  the  natural  passage  is  possible.  . 


Fig.  384. — Normal  diameters  of  the  pelvic  outlet. 


Fig.  385. — Marked  shortening  of  the  transverse  diameter,  but  ample  room  furnished  by 

the  posterior  sagittal. 


Fig.  386. — Wider  transverse  diameter,   but  passage  of   head  impossible   on   account  of 
shortened  posterior  sagittal  diameter. 


The  dangers  of  the  funnel-shaped  pelvis  are  many  and  concern  both 
the  mother  and  the  fetus.    Aside  from  the  danger  of  extensive  lacerations 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      659 

of  the  mother,  the  long  pressure  of  the  soft  parts  against  the  bony  pro- 
jections of  the  pelvic  outlet,  especially  if  the  correct  diagnosis  has  been 
overlooked  and  the  case  neglected,  tends  to  sloughing  and  fistulse  and 
the  forcible  extraction  of  the  child  in  these  neglected  cases  tends  to 
injury  of  the  pelvic  articulations. 

The  fetal  dangers  naturally  depend  upon  the  degree  of  pelvic  deform- 
ity, the  time  of  diagnosis,  and  tjie  method  of  deliver3\  If  neglected  and 
left  too  long  upon  the  floor  of  the  pelvis  the  life  of  the  fetus  is  lost  from 
interference  with  the  placental  circulation. 

If  dragged  through  the  narrow  outlet  by  brute  force  the  child  is  usually 
lost  from  cranial  and  cerebral  injuries. 

The  method  of  delivery  indicated  varies  with  the  degree  of  contraction 
in  the  individual  case.  In  the  lower  grades  of  contraction  delivery  may 
take  place  unaided  or  by  an  easy  forceps  operation,  while  in  the  high 
degrees  of  contraction  delivery  of  a  living  child  may  onlj'  be  possible 
through  a  pubiotomy  or  Cesarean  section.  The  safety  of  mother  and 
child  requires  that  a  transverse  diameter  of  the  pelvis  contracted  to 
8  cm.  or  less  should  be  looked  upon  with  suspicion  and  the  labor  watched 
for  early  indications  for  operative  interference. 

Imperfect  Development  of  One  Sacral  Ala.  Obliquely  Contracted 
Pelvis  of  Naegele.— This  tj^^e  of  deformed  pelvis  was  first  described  by 
Naegele^  who,  in  1839,  published  a  monograph  based  upon  35  cases. 
The  condition  is  a  rare  one.  In  the  series  of  1770  deformed  pelves  occur- 
ring in  20,000  consecutive  deliveries  at  the  Sloane  Hospital  there  were 
18  obliquely  contracted  pelves,  or  1  per  cent.  In  the  1170  whites  of 
this  series  there  were  13,  or  1.1  per  cent.  In  the  600  blacks  there  were 
5,  or  0.8  per  cent. 

Characteristics. — ^The  pelvis  of  Naegele  is  an  asymmetrical  one  whether 
viewed  from  above  or  below,  from  in  front  or  behind.  The  posterior 
portion  of  the  innominate  bone  on  the  affected  side  lies  in  close  apposition 
with  the  sacrum  and  in  such  a  way  that  that  side  of  the  pelvic  cavity  is 
flattened  out. 

The  sacrum  is  asymmetrical,  much  narrowed  on  the  affected  side  and 
is  turned  so  as  to  look  toward  this  side  (see  Fig.  387).  The  promontory 
is  deflected  toward  the  diseased  side  of  the  pelvis.  The  symphysis  pubis 
is  deflected  toward  the  sound  side,  but  its  external  surface  faces  a  little 
toward  the  affected  side  rather  than  directly  forward.  The  iliopectineal 
line  on  the  affected  side  is  markedly  straightened,  while  on  the  opposite 
side  its  curvature  is  increased. 

This  gives  to  the  pelvic  brim  the  shape  of  an  irregular  oval  with  long 
diameter  between  the  sacro-iliac  joint  on  the  affected  side  and  the  ilio- 
pectineal eminence  on  the  sound  side.  The  internal  oblique  diameter 
from  sacro-iliac  joint  of  sound  side  to  iliopectineal  eminence  of  affected 
side  is  usually  markedly  shortened. 

The  internal  conjugate  diameters,  both  diagonal  and  true,  are  directed 
obliquely  and  are  usually  somewhat  lengthened.      The  pubic  arch  is 

1  Das  Schriig  vereagte  Becken,  Mainz,  1839.  '  ' 


660 


ABNORMAL   LABOR  FROM  ANOMALIES  IN  PASSAGES 


irregularly  contracted  as  the  rami  of  ischium  and  pubes  are  pushed  inward 
toward  the  sound  side  of  the  pelvis.    The  acetabulum  of  the  affected  side 


Fig.  387. — Naegele  pehds,  supeiior  ^'iew.     (Naegelc.) 

looks  more  anteriorly  than  normal,  while  on  the  opposite  side  it  looks 
almost  directly  outward.  The  iliac  fossa  of  the  sound  side  is  directed 
nearly  forward,  while  on  the  affected  side  it  is  directed  inward. 


Fig.  .388. — Naegele  pelvi.-;,  posterior  view.     (Naegele.) 

On  looking  into  the'cavity  of  the  pelvis  from  above,  if  the  deformity 
is  Avell  marked  it  is  seen  that  the  great  sacrosciatic  notch  on  the  affected 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      6G1 

side  is  almost  obliterated  and  the  tuberosity  of  the  ischium  lies  nearly 
in  apposition  with  the  sacrum  and  projects  into  the  pelvic  canal. 

When  viewed  from  behind  (see  Fig.  38S),  the  posterior  superior  iliac 
spine  of  the  affected  side  is  seen  to  lie  in  close  apposition  with  the  spines 
of  the  sacrum  and  the  obliteration  of  the  great  sacrosciatic  notch  on  that 
side  is  seen  in  marked  contrast  to  that  of  the  opposite  side. 

Etiology. — The  characteristic  shape  of  the  Naegele  pelvis  depends 
upon  the  imperfect  development  or  absence  of  the  alse  of  the  sacral 
vertebrae  on  one  side.  Usually,  but  not  always,  there  is  a  synostosis  of 
the  sacrum  and  the  innominate  bone  on  this  side.  The  origin  of  this 
deformity  has  been  the  subject  of  much  discussion,  some  claiming  the 
view  expressed  above  that  the  synostosis  was  only  secondary  to  a 
primarj^  sacral  defect;  others  claiming  that  the  primary  lesion  was  an 
inflammation  which  caused  an  ankylosis  and  subsequent  deformity. 
The  view  generally  accepted  today  is  the  one  first  expressed,  i.  e.,  that 
there  is  first  a  defect  in  development:  an  absence  of  the  bony  nuclei 
in  the  alee  on  one  side  of  the  sacrum.  The  reasons  for  this  belief  are 
numerous.  There  is  no  history  of  inflammation.  The  alee  are  lacking 
not  only  in  the  sacral  vertebrae  which  enter  into  the  formation  of  the 
sacro-iliac  joint,  but  along  the  whole  length  of  the  sacrum.  If  there  was 
a  primary  ankylosis  the  subsequent  displacement  upward  and  backward 
would  be  impossible. 

As  a  result  of  the  lack  of  development  in  the  sacral  alee  the  innominate 
bone  tends  to  slide  past  the  normal  site  of  the  sacro-iliac  joint  and  to 
come  in  contact  with  the  bodies  of  the  sacral  vertebrae. 

This  tendency  existing  in  infant  life  is  greatly  exaggerated  when  the 
child  begins  to  walk  and  more  and  more  pressure  is  transmitted  from  the 
femur  up  through  the  poorly  arched  innominate  bone  of  the  affected  side. 
The  friction  and  irritation  caused  by  this  abnormal  mobility  usually 
results  in  inflammation,  atrophy,  and  ankylosis  of  the  joint. 

Diagnosis. — ^As  patients  with  an  obliquely  contracted  pelvis  may  have 
no  limp  in  their  gait,  unless  careful  pelvimetry  is  carried  out  as  a  routine 
procedure  in  every  case  of  pregnancy,  the  condition  may  be  entirely 
overlooked  until  labor  is  well  advanced.  There  is  usually  little  difficulty, 
how^ever,  in  making  the  diagnosis  if  the  ordinary  pelvic  measurements 
are  carefully  taken,  especially  the  oblique  diameters,  and  th^  pelvic 
cavity  is  carefully  palpated.  If  the  deformity  is  marked,  the  right  and 
left  oblique  diameters,  measured  externaUy,  while  normally  differing  by 
only  a  fraction  of  1  cm.,  will  be  found  in  a  Naegele  pelvis  to  be  markedly 
unequal.    This  should  attract  attention  to  an  abnormality. 

This  asymmetry  may  then  be  verified  by  measuring  from  the  last 
lumbar  spine  to  the  anterior  superior  spine  on  either  side.  Furthermore, 
the  palpation  of  the  pelvic  cavity,  bringing  out  the  facts  that  one  side 
of  the  pelvis — the  diseased  side — is  flattened  out  and  lies  nearer  the 
median  line  than  the  other;  that  the  pubic  arch  does  not  lie  opposite 
the  middle  of  the  sacrum  but  toward  the  sound  side;  that  the  spine  of 
the  ischium  lies  close  to  the  sacrum  on  the  diseased  side,  these  palpation 
findings  taken  in  conjunction  with  the  inequality  of  the  external  oblique 


662        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

diameters  should  enable  the  diagnosis  of  a  Naegele  pelvis  to  he  made. 
For  purposes  of  classification  a  difference  of  2  cm.  in  the  oblique  diameters 
is  sufficient  to  place  a  pelvis  in  the  class  of  obliquely  contracted. 

Influence  on  Labor. — The  mechanism  of  labor  in  a  Naegele  pelvis  is 
similar  to  that  in  a  generally  contracted  pelvis.  The  only  portion  of  the 
pelvic  cavity  available  for  parturition  is  the  sound  side,  and  through 
this  sound  side,  if  the  child  is  small  and  uterine  contractions  strong,  the 
head  in  extreme  flexion  may  pass.  If  the  child  presents  by  the  breech, 
the  delay  in  the  delivery  of  the  after-coming  head  is  apt  to  give  a  high 
fetal  mortality. 

The  maternal  mortality  of  labor  in  this  variety  of  pelvic  deformity 
depends  upon  the  degree  of  contraction,  the  time  of  diagnosis,  and  the 
method  of  deli^•ery.    The  prognosis  may  always  })e  considered  grave. 

Litzman,  in  a  series  of  41  cases,  lost  79  per  cent,  of  the  mothers  in  the 
first  labor,  and  only  15  per  cent,   of  the  labors  ended  spontaneously. 


Fig.  380. — Transversely  contracted  Robert  pelvis.      (Robert.) 

The  results  of  Litzman,  however,  occurred  in  1853,  and  do  not  represent 
the  present-day  methods  of  early  accurate  pelvimetry'  and  improved 
technic  in  operative  delivery. 

Method  of  Delivery. — .Spontaneous  labor  should  only  be  waited  for  in 
cases  where  the  sound  half  of  the  pelvis  seems  roomy,  and  careful  com- 
parison of  the  relative  size  of  head  and  pelvis  gives  a  favorable  prognosis. 
In  cases  with  marked  contraction  and  in  doubtful  cases,  unless  a  short 
test  of  labor  justifies  hope  in  the  powers  of  nature,  the  best  result  will 
come  from  an  early  resort  to  Cesarean  section.  Induction  of  premature 
labor  would  only  be  indicated  in  very  minor  degrees  of  contraction  and 
is  seldom  to  be  recommended. 

The  Double  Obliquely  Contracted  Pelvis.  The  Transversely  Con- 
tracted Pelvis  or  the  Robert  Pelvis. — This  variety  of  pelvic  deformity 
was  first  described  by  Robert^  in  1842. 

1  Beschreibung  eines  im  hochsten  Grade  querver^ngten  Beckens,  U.  S.  W.,  Karlsruhe 
u.  Freiburg,  1842. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      663 

Characteristics. — In  the  Robert  pelvis  (see  Fig.  389)  the  imperfect 
development  of  the  sacral  alse,  which  in  the  Naegele  pelvis  involves  only 
one  side,  is  bilateral.  This  gives  a  pelvis  which  is  markedly  contracted 
transversely  and  is  often  spoken  of  as  the  double,  obliquely  contracted, 
or  double  Naegele  pelvis. 

The  sacral  alse  are  usually  both  absent  and  the  innominate  bones  and 
the  imperfectly  developed  sacrum  ankylosed.  The  ankylosis,  however, 
is  not  uniformly  present  and  one  of  the  sacral  else  may  be  slightly  devel- 
oped, giving  a  slight  asymmetry  to  the  pelvis. 

The  Robert  pelvis  is  markedly  contracted  in  its  transverse  diameters. 
The  sacrum  is  extremely  narrow  and  the  posterosuperior  iliac  spines 
and  the  spines  and  tuberosities  of  the  ischia  are  brought  close  together. 
The  anterior  surface  of  the  sacrum  is  apt  to  be  convex  in  both  directions, 
and  the  sacrum  as  a  whole  has  a  slight  anterior  displacement,  but  the 
shortening  of  the  anteroposterior  diameter  is  so  slight  in  comparison  with 
the  transverse  that  it  seems  practically  normal. 

The  Robert  pelvis  is  one  of  the  rarest  of  the  pelvic  deformities.  In 
the  series  of  20,000  consecutive  deliveries  at  the  Sloane  Hospital  no  case 
of  Robert  pelvis  was  found. 

Diagnosis. — ^As  a  rule  the  condition  is  recognized  without  difficulty, 
as  the  transverse  diameters  of  the  pelvis  measured  externally  are  all 
markedly  shortened,  while  the  external  conjugate  remains  nearly  normal. 
The  pubic  arch  is  distinctly  narrowed  and  internal  examination  shows  the 
sides  of  the  pelvis  approximated. 

Influence  on  Labor. — The  degree  of  contraction  in  the  typical  Robert 
pelvis  is  such  that  delivery  per  vias  naturales  is  impossible,  and  as  induc- 
tion of  premature  labor  is  impracticable,  Cesarean  section  is  the  only 
rational  method  of  delivery  if  the  child  is  alive. 

The  Generally,  Equally  Enlarged  Pelvis.  Justomajor  Pelvis. — A 
pelvis  in  which  all  the  measurements  are  far  in  excess  of  the  normal, 
although  preserving  their  normal  relations.  Although  an  arbitrary 
classification,  it  is  the  custom,  as  already  stated,  at  the  Sloane  Hospital 
to  call  equally  enlarged  pelves  whose  oblique  diameters  measure  24  cm. 
or  over,  justomajor  pelves. 

Frequency. — ^These  abnormally  large  pelves  are  frequently  found  in 
women  of  gigantic  stature  and  occasionally  in  women  of  medium  size. 

If  careful  pelvimetry  is  followed  in  every  obstetric  case  a  much  larger 
number  of  justomajor  pelves  will  be  found  than  is  generally  supposed. 

Diagnosis. — ^The  condition  is  readily  determined  by  pelvimetry  and 
noting  that  not  a  few  but  all  the  diameters  of  the  pelvis  are  enlarged 
and  the  relative  proportions  are  maintained. 

Influence  on  Labor. — Under  ordinary  circumstances  the  labor  is  little 
influenced  by  an  equally  enlarged  pelvis,  except  for  the  fact  that  there 
is  no  obstruction  from  a  narrowing  of  the  bony  canal. 

The  women  of  gigantic  stature  often  have  large  children  and  especially 
in  first  labors,  these,  as  well  as  medium-sized  women  with  abnormally 
large  pelves,  usually  present  normal,  easy  labors.  Occasionally,  however, 
in  multigravidse  with  justomajor  pelves  and  with  pelvic  floor  lacerated 


004        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

or  badly  stretched,  the  i:)re(|;iiaiit  uterus  hes  low  in  the  pelvis  with  unusual 
pressure  upon  rectum,  bladder  and  pelvic  veins,  resulting  in  various 
discomforts  to  the  woman,  such  as  constipation,  frecjuent  micturition, 
edema  of  the  vulva  and  lower  extremities,  and  difficult  locomotion. 

JMoreover,  the  labor  in  these  cases  may  be  precipitate  with  little 
mechanism  and  with  an  increase  of  existing  lacerations. 

The  Split  Pelvis. — This  is  due  to  a  defect  in  the  development  of  the 
lower  i)ortion  of  the  trunk  in  front  and  not  only  is  there  an  absence  of 
union  of  the  pubic  bones  at  the  symphysis  (see  Fig.  390),  but  there  are 
usually  other  malformations  present,  such  as  exstrophy  of  the  bladder, 
spina  bifida,  etc.  The  space  between  the  ends  of  the  pubic  bones  is  usually 
filled  Avith  fibrous  tissue  which  is  more  or  less  yielding,  and  the  pressure 
upward  through  the  femora  forces  the  innominate  bones  outward  and 
upward,  approximating  the  posterior  superior  spines  of  the  ilium  and 
projecting  the  sacrum  forward. 


Fig.  390. — Split  pelvis.     (Breus  and  Kolisko.) 


Frequency  and  Influence  on  Labor. — The  split  pelvis  is  one  of  the  rarest 
of  pelvic  deformities  encountered  as  a  complication  of  pregnancy  and 
labor,  although  there  are  a  few^  cases  on  record.  The  reason  for  the 
rarity  is  obviously  not  only  the  rarity  of  the  malformation,  but  the  fact 
that  such  women  with  exstrophy  of  the  bladder  and  other  faults  in  devel- 
opment are  not  as  likely  to  be  attractive  to  the  opposite  sex. 

Labor  in  the  split  pelvis  has  many  of  the  characteristics  of  that  in 
the  justomajor  pelvis.  It  is  usually  fairly  rapid  and  easy,  although  the 
absence  of  the  resistant  anterior  pelvic  wall  usually  interferes  with  the 
normal  mechanism  in  flexion  and  rotation.  After  the  labor  there  has 
resulted  in  some  cases  a  prolapse  of  the  pelvic  organs. 


ANOMALIES  OF  HARD   PARTS  OF  PARTURIENT  CANAL      665 

Pelvic  Anomalies  Resulting  from  Disease  of  the  Pelvic  Bones. 

The  Rachitic  Pelvis. — Frequency. — The  disease  which  is  most  often  the 
cause  of  pelvic  deformity  in  this  country,  especially  among  the  colored 
race,  is  rachitis — rickets.  In  the  white  race  it  is  of  infrequent  occur- 
rence, but  in  the  colored  race  not  only  in  the  South,  but  in  the  large 
cities  like  New  York,  it  is  common. 

Williams,  at  the  Johns  Hopkins  Hospital,  found  6  per  cent,  of  the 
deformed  pelves  occurring  in  white  women,  and  22  per  cent,  of  those  in 
colored  women  were  rachitic  in  origin.  In  the  dispensaries  of  Vienna, 
Berlin  and  other  parts  of  Europe,  pelves  deformed  by  rachitis  are 
frequently  seen. 

Etiology. — Rachitis  is  a  disease  of  malnutrition,  and  when  the  difficulty 
experienced  by  the  colored  population  of  a  city  like  New  York  in  securing 
airy,  healthful  tenements  within  their  means  is  considered,  it  is  not 
difficult  to  understand  the  result. 

The  colored  tenements  are  usually  poorly  lighted,  poorly  ventilated, 
and  overcrowded,  and  if  with  this  is  coupled  insufficient  food  of  improper 
quality,  it  is  not  surprising  to  see  in  them  children  presenting  all  the 
evidences  of  the  disease  in  question. 

Furthermore,  the  white  race  is  not  exempt  nor  need  it  be  confined  to 
the  tenements,  for  in  the  early  days  of  enthusiasm  over  laboratory 
methods  of  infant  feeding  and  milk  sterilization,  here  and  there  in  a 
palatial  residence  a  child  could  be  found  presenting  the  early  symptoms 
of  rachitis  produced  by  improper  nourishment.  Fortunately  our  knowl- 
edge of  artificial  feeding  has  increased  and  the  dangers  just  alluded  to 
have  been  recognized  and  are  usually  avoided. 

Pathology. — Before  discussing  the  type  of  deformity  produced  in  the 
pelvis  by  rachitis,  it  would  be  well  to  consider  briefly  the  pathology  of 
the  disease  itself.  In  the  normal  growth  and  development  of  healthy 
bone  two  chief  processes  are  going  on: 

1.  At  the  periphery  a  proliferation  of  cells  intended  for  bone  structure. 

2.  An  associated  calcification  of  these  cells. 
These  processes  are  seen  in  Fig.  391. 

In  rachitis  these  processes  are  markedly  disturbed  (see  Fig.  392). 
The  proliferation  of  cells  at  the  periphery  goes  on  more  rapidly  than  is 
normal,  while  the  calcification  of  these  cells  is  less  than  normal.  It  is 
estimated  that  in  rachitic  bone  the  deposit  of  inorganic  salts  is  only  one- 
third  that  in  normal  bone.  This  gives  a  pelvis  which  is  pliable  and  yields 
more  readily  to  the  forces  to  which  it  is  subjected,  viz.: 

Pressure  from  above. 

Counter-pressure  from  below. 

Traction  by  muscles  and  ligaments. 

The  condition  of  the  bone  in  rachitis  differs  entirely  from  that  in 
osteomalacia,  as  in  the  former  calcification  has  never  taken  place  while 
in  the  latter  calcification  w^as  previously  complete,  but  was  followed  by 
softening.  Furthermore,  the  lack  of  calcification  and  softening  in  rachitis 
is  more  marked  at  the  epiphyses  of  the  long  bones,  although  it  does  occur 


660        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

to  a  less  extent  under  the  periosteum  of  the  long  and  flat  bones.  In 
osteomalacia  the  softening  is  more  uniform  throughout  the  bone  substance. 
Rachitis  may  be  fetal,  i.  e.,  develop  in  utero,  and  at  birth  the  infant 
presents  abnormalities  produced  by  muscular  action  upon  the  softened 
bones;  or  more  commonly  it  develops  during  early  childhood,  and  depend- 
ing upon  the  age  at  which  calcification  finally  takes  place,  the  bones  in 
general  and  the  pelvis  in  particular,  vn[\  present  different  abnormalities. 


a ' 


id 


^ 


Fig.  391. — Section  tlu'ough  oiiitication  zone  of  noriual  bone;  a,  hyaline  carlilage;  h,  zone 
of  beginning  cartilage  proliferation;  c,  columns  of  cartilage  cells;  d,  columns  of  hypertrophic 
cartilage;  e,  zone  of  temporarj-  calcification;  /,  zone  of  primary  medullary  spaces;  g,  zone 
of  primary  bone  formation;  h,  fully  developed  spongy  bone;  t,  bloodvessels;  A;,  layer  of 
osteoblasts.     (Ziegler.) 


It  is  readily  understood  that  the  pelvis  of  a  child  suffering  from  rickets 
in  which  ossification  took  place  before  the  child  stood,  walked,  or  worked, 
will  be  less  deformed  than  one  in  which  the  disease  was  in  active  progress 
during  the  teens  of  the  child  when  both  at  work  and  at  play  the  pressure 
upon  the  pliable  pelvis  from  above  and  below  and  through  muscles  and 
ligaments  was  continued  for  years  with  steadily  increasing  deformity. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      667 


Fig.  392. Bone  in  rickets.     Longitudinal  section  of  a  rib  at  the  junction  of  the  costal 

cartilage  hi  a  severe  case  of  rickets  (slightly  magnified).  C,  costal  cartilage;  B,  bone; 
A  proliferating  cartilage  zone  which  is  much  widened.  Between  the  hypertrophied  car- 
tilage cell-columns  (a)  making  up  this  proliferating  zone  are  seen  medullary  spaces  (b) 
containing  bloodvessels.  In  this  zone  He  masses  of  bone  (c)  not  calcified.  The  calcification 
zone  is  almost  wanting,  only  scattered  islands  (d)  of  calcified  cartilage  cells  being  seen. 
Beyond  this  proliferating  zone  (A)  is  a  layer  of  bony  tissue  (£)  made  of  up  small  bands,  of 
which  only  a  few  have  a  nucleus  containing  lime  (e).  These  nuclei  appear  black.  The  bony 
bands  differ  both  in  form  and  arrangement  from  those  of  normal  ossification.  Between 
the  bony  masses  are  medullary  spaces  which  appear  light  in  the  illustration.  At  (g)  the 
beginning  of  cartilage  proliferation  is  seen.  Above  this  zone  the  cartilage  is  normal.  (From 
Karg  and  Schmorl.) 


608 


ABNORMAL   LABOR  FROM  ANOMALIES  IX  PASSAGES 


III  considering  tlie  effect  of  rachitis  u])on  a  peKis.  it  should  l)e  reniein- 
l)ered  that  calcification  eventually  takes  place  in  a  rachitic  ])elvis  and  in 
obstetrics  the  obstetrician  has  to  deal  with  the  crystali/ed  result  of 
damage  done  to  a  i)eKis  which  was  yielding  at  a  time  during  the  develop- 
mental j)erio(l  of  youth  when  it  should  have  been  firm. 

Varieties. — Depending  upon  the  extent  of  the  disease,  its  duration, 
and  the  age  of  the  individual  at  which  the  process  ceased,  the  following 
varieties  of  pelvic  deformity  are  produced  by  rachitis: 

1.  Flat,  generally  contracted  rachitic. 

2.  Simjile  flat  rachitic. 

3.  Generally  equally  contracted  rachitic. 

4.  Pseudo-osteomalacie. 

By  comparing  these  varieties  with  the  deformities  arising  from  faulty 
development  (see  page  050)  it  will  be  seen  that  the  first  three  are  the 
same,  although  in  a  different  order  of  frequency. 


Fig.  393. — Sharp  bend  in  posterior  pehdc  wall  of  rachitic  pelvis.     (Bumm.) 


The  Flat,  Generally  Contracted  Rachitic  Pelvis. — This  is  the 
most  common  form  of  pelvic  deformity  found  in  women  who  in  early 
life  have  been  afflicted  with  rachitis  and  may  be  looked  upon  as  the 
typical  rachitic  pelvis.  The  arrested  development  due  to  the  malnutri- 
tion and  presence  of  disease  easily  explains  the  general  reduction  in  the 
size  of  the  pehis.  The  typical  shape  of  the  rachitic  pelvis  will  be  under- 
stood if  its  mode  of  production  is  studied. 

Characteristics.— The  sacrum  is  pushed  downward  and  forward  between 
the  iliac  bones  and  is  rotated  on  its  transverse  axis  mainly  by  the  pressure 
of  the  trunk  upon  it,  but  partly  by  the  downward  ])ull  of  the  psoas  muscles 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      669 

upon  the  spinal  column  and  the  upward  pull  of  the  erector  spinse  muscles 
upon  the  posterior  surface  of  the  sacrum.  This  would  naturally  tend  to 
throw  the  tip  of  the  sacrum  and  the  coccyx  directly  backward.  The 
attachment  of  the  sacrosciatic  ligaments  and  the  pelvic  muscles  to  the 
lower  part  of  the  sacrum  and  cocc}x,  however,  prevent  this  backward 
movement  of  the  posterior  pelvic  wall  as  a  whole  and  pulling  the  lower 
portion  forward  cause  a  sharp  bend  in  it,  usually  near  the  third  or  fourth, 
sometimes  the  fifth,  sacral  vertebra  (see  Fig.  393). 

In  its  longitudinal  axis  the  sacrum  shows  a  lessening  of  its  anterior 
vertical  concavity  above  (in  some  cases  there  may  even  be  a  vertical 
convexity)  and  an  increase  below.  In  some  cases  the  body  of  the  first 
sacral  vertebra  projects  more  than  the  others  and  forms  a  false  promon- 
tory. By  the  forward  movement  of  the  bodies  of  the  sacral  vertebrae 
the  transverse  concavity  of  the  anterior  surface  is  diminished,  and  in 
some  cases  the  anterior  surface  of  the  sacrum  may  indeed  be  convex 
from  side  to  side. 


Fig.  394. — Anterior  divergence  of  the  innominate  bones;  rachitic  pelvis.     (Bumm.) 

By  the  pull  of  the  strong  sacro-iliac  ligaments,  together  with  the  weight 
of  the  trunk  upon  the  sacrum,  the  posterosuperior  iliac  spines  are  drawn 
downward,  inward,  and  forward.  This  tends  to  throw  the  anterior  half 
of  the  innominate  bones  outward  (see  Fig.  394). 

Although  this  is  prevented  in  part  by  the  symphysis  pubis  and  Pou- 
part's  ligaments,  still  the  ilia  are  thrown  somewhat  outward,  so  that  the 
distance  between  the  anterior  superior  iliac  spines  becomes  little  less  than, 
equal  to,  or  even  greater  than,  the  distance  between  the  iliac  crests.  This  is 
the  practical  criterion  of  a  rachitic  pelvis. 

A  further  result  of  the  pulling  inward  and  forward  of  the  posterior 
portion  of  the  innominate  bones  is  to  produce  in  them  an  abnormal 
anteroposterior  curvature;  the  point  of  greatest  curvature  being  found 
on  the  iliopectineal  line  just  in  front  of  the  sacro-iliac  joints  and  posterior 
to  the  median  transverse  line  of  the  pelvic  inlet.  On  account  of  this 
flexion  of  the  innominate  bones  the  transverse  diameter  of  a  rachitic 
pelvis  is  relatively  increased,  but,  as  the  pelvis  is  usually  below  normal 
in  size,  its  transverse  diameter  rarely  exceeds,  if  indeed  it  actually  equals, 
the  normal. 

Furthermore,  the  projection  forward  of  the  sacrum   (see  Fig.    394) 


G7()        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

prevents  this  transverse  diameter  from  being  accessible  to  the  fetal  head 
by  crowding  it  forward  to  where  the  transverse  diameter  is  narrower. 
The  anteroposterior  flexion  of  the  innominate  bones  has  a  further  effect 
of  throwing  the  acetabula  forward  so  that  the  pressure  from  below  upward 
through  the  femora  is  exerted  more  anteroposterior! y  than  in  the  normal 
pelvis. 

The  resistance  at  the  symphysis  pubis  to  the  outward  rotaticn  of  the 
innominate  bones  has  the  tendency  to  bend  the  ends  of  the  pubic  bones 
inward  toward  the  pelvic  canal. 

The  projection  of  the  sacrum  forward  and  of  the  symphysis  backward 
gives  the  pelvic  inlet  in  a  well-marked  rachitic  pelvis  the  shape  of  the 
figure  8,  and  it  is  sometimes  called  "the  figure-of-eight  pelvis." 

According  to  the  degree  of  inbending  of  the  symphysis  pubis  in  a  rachitic 
pelvis,  the  shape  of  the  inlet  may  be  cordiform,  reniform,  or  that  of  the 
figure  eight.  Through  the  traction  of  the  adductor  and  rotator  muscles 
of  the  thighs  upon  the  tuberosities  of  the  ischia  (increased  in  rachitis 
on  account  of  the  anterior  position  of  the  acetabula  and  the  bowing  of 
the  femora),  the  tuberosities  are  pulled  outward  and  forward  so  that  the 
pubic  arch  is  greatly  widened  and  the  transverse  diameter  of  the  outlet 
is  increased.  This  result  is  also  favored  when,  on  account  of  the  disease, 
walking  of  the  child  is  long  delayed  and  much  of  the  time  is  spent  in  the 
sitting  posture,  thus  bringing  the  weight  and  pressure  of  the  trunk  upon 
the  tubera  ischii  without  the  counter-pressure  from  below  through  the 
femora. 

We  have  then,  in  a  typical  rachitic  pelvis  usually  one  which  is  smaller 
than  normal  and  with  bones  thinner  and  more  delicate  than  would  be 
found  in  a  woman  always  healthy.  Occasionally,  however,  the  bones 
are  thicker  and  heavier  than  usual. 

On  account  of  the  rotation  forward  of  the  sacrum  and  the  lordosis 
which  so  often  accompanies  it,  the  anterior  inclination  of  the  pelvis  is 
increased  and  the  external  genitals  are  displaced  backward.  The  iliac 
fossse  look  more  anteriorly  than  in  the  normal  pelvis;  the  pelvic  cavity 
is  shallow;  the  inlet  is  narrowed,  especially  in  its  conjugate,  and  the 
outlet  is  relatively,  if  not  actually,  enlarged  by  the  widening  of  the  pubic 
arch  and  separation  of  the  tuberosities  of  the  ischia. 

Diagnosis. — As  far  as  the  pelvis  itself  is  concerned,  its  rachitic  character 
is  determined  by  one  criterion.  The  distance  between  the  anterosuperior 
spines  of  the  ilia  approximates  or  exceeds  the  distance  between  the  iliac 
crests.  In  connection  with  this,  to  complete  the  picture,  must  be  taken 
the  patient's  early  history  and  her  present  bone  condition. 

If  her  early  history  can  be  obtained  it  will  usually  be  found  that  she 
was  late  in  beginning  to  walk,  perhaps  three  or  four  years  of  age,  and 
that  she  was  also  late  in  teething.  Her  present  condition  is  one  of  small 
stature,  with  short,  thick,  curved  extremities,  the  tibiae  especially  showing 
curved,  sharp  anterior  borders  (Fig.  395).  The  joints  are  enlarged  and 
as  the  patient  walks,  her  bow-legged  condition  is  easily  seen.  Her  brow 
is  low  and  broad  and  her  nose  is  flat,  she  often  has  the  so-called  "  chicken 
breast."    This  is  the  picture  of  a  rachitic  patient. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      671 


Influence  on  Labor. — On  considering  the  shape  and  size  of  the  typical 
rachitic  pelvis,  its  influence  upon  labor  is  readily  understood.  Most  of 
the  difficulty  arises  at  the  inlet  of  the  pelvis  and  if  this  is  passed  the 
labor  usually  proceeds  easily.  The  mechanism  of  labor  resembles  some- 
what that  described  in  the  simple,  flat  pelvis,  from  faulty  development, 
but  in  the  rachitic  pelvis  the  narrowing  of  the  conjugate  at  the  brim  is 
greater  than  in  the  simple  flat,  because  the  sacrum  is  rotated  forward  on 
its  transverse  axis  instead  of  being  carried  forward  as  a  whole.  As  a 
result  of  this  the  promontory  is  more 
prominent  and  the  obstruction  usually 
greater.  On  the  other  hand,  the  rachitic 
pelvis  has  a  cavity  which  is  more  shallow 
and  more  roomy  and  an  outlet  which  is 
larger  than  in  the  simple  flat.  Hence 
the  labor  in  a  rachitic  pelvis,  when  once 
the  brim  plane  is  passed,  is  easier  than  in 
the  simple  flat,  and  much  easier  than  in 
the  generally  equally  contracted  flat  pelvis 
arising  from  faulty  development. 

The  Simple  Flat,  Rachitic  Pelvis. — 
Here  we  have  a  condition  in  which  only 
the  conjugate  diameter  is  reduced,  the 
transverse  diameter  remaining  unaltered. 
This  is  a  less  common  form  of  the  rachitic 
pelvis  than  the  flat,  generally  contracted 
rachitic  just  considered,  and  represents 
either  less  malnutrition  and  a  lesser  degree 
of  disease  or  else  a  shorter  course,  and  a 
completed  ossification  before  the  deform- 
ing forces  could  exert  great  influence. 
The  diagnosis  is  made  by  careful  pelvim- 
etry determining  a  disturbance  of  the 
normal  relation  between  the  interspinous 
and  intercristal  diameters  and  by  a  care- 
ful study  of  the  history  of  the  case.  Its 
influence  upon  the  labor  depends  entirely 
upon  the  degree  of  flattening. 

The  Generally  Equally  Contracted, 
Rachitic  Pelvis. — This  is  a  rare  type  of 

rachitic  pelvis  and  represents  chiefly  the  result  of  malnutrition  in  a 
patient  who  has  been  afflicted  with  rachitis,  the  disease  beginning 
and  reaching  its  termination  before  the  child  sat  up  or  walked,  hence 
before  the  pelvis  was  subjected  to  much  pressure. 

The  diameters  of  the  pelvic  inlet  are  equally  shortened  and  the  diag- 
nosis is  made  by  general  evidences  of  a  past  rachitis  and  sometimes  by 
changes  in  the  sacrum  and  separation  of  the  tuberosities  of  the  ischia. 
This  is  the  only  type  of  rachitic  pelvis  in  which  the  normal  relation 
between  the  interspinous  and  intercristal  diameters  may  be  unchanged. 


Fig.  395. — Rachitic  patient, 
showing  bow-legs  and  tibiae  with 
sharp,  curved  anterior  borders. 


G72        ABNORMAL  LABOR  FROM  ANOMALIES  IX  PASSAGES 

The  influence  ui)()n  labor  closely  resembles  that  of  a  generally  equally 
contracted  pelvis  from  faulty  development,  save  that  in  the  pelvis  con- 
tracted from  rachitis,  the  labor  is  easier  after  the  brim  plane  has  been 
passed,  on  account  of  the  lessened  depth  of  the  pelvis  and  the  widening 
of  the  pubic  arch. 

The  Pseudo-osteomalacic,  Rachitic  Pelvis.  —  Here  the  rachitis 
has  progressed  to  an  extreme  degree  and  through  a  long  ])eriod  during 
which,  while  the  disease  was  in  active  progress,  not  only  have  efl'orts 
at  walking  been  made,  but  the  weight  of  the  trunk  possibly  exaggerated 
by  carrying  heavy  burdens  has  been  added.  The  sacrum  sinks  far  down 
into  the  pelvic  canal  and  is  sharpl\"  cur\ed  from  above  downward 
anteriorly.  The  acetabula  are  pressed  inward  upon  the  pelvic  canal 
(see  Fig.  396)  and  the  anteroposterior  flexion  of  the  innominate  bones 
is  extreme. 

When  the  disease  has  rim  its  course,  the  pelvis  is  firmly  set  in  markedly 
distorted  shape.     The  differential  diagnosis  between  the  pseudo-osteo- 


FiG.  396. — Pseudo-osteomalacic  pel\ns.      (Xaegele.) 

malacic  pelvis  of  rachitis  and  the  pelvis  of  true  osteomalacia  is  made 
by  applying  the  usual  criterion  of  rachitis,  /.  e.,  the  disturbed  relation 
between  the  interspinous  and  intercristal  diameters;  by  determining  the 
fact  that  ossification  occurred  for  the  first  time  after  the  disease  was 
arrested,  and  by  finding  evidences  of  rachitis  in  other  parts  of  the  ix)dy. 

Furthermore,  osteomalacia  has  certain  peculiarities  of  its  own  which 
usually  enable  one  to  recognize  it.    These  will  be  studied  later. 

The  Osteomalacic  Pelvis. —  The  disease  causing  the  most  marked 
l)elvic  deformities  encountered  by  the  obstetrician  is  known  as  osteo- 
malacia, malocosteon,  or  mollities  ossium. 

It  is  characterized  by  a  general  softening  of  the  bone  tissue  in  difi'erent 
portions  of  the  skeleton,  complete  normal  ossification  having  previously 
taken  place,  thus  differing  from  rachitis,  in  which  ossification  does  not 
become  comj^lete  until  after  the  termination  of  the  disease. 

Frequency  and  Etiology. — In  America  the  disease  is  a  rare  one,  less  than 
a  score  of  cases  having  been  reported.  At  the  Sloane  Hospital  in  20,000 
consecutive   labors  onlv  1  case  of  osteomalacia  was  found.     In   Ger- 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      673 

many,  Switzerland  and  Italy,  however,  it  has  been  quite  common.  The 
disease  and  its  effect  upon  the  pelvis  were  well  known  to  Stein  and  Kilian 
in  the  early  part  of  the  last  century,  and  in  1861  Litzman  had  collected 
from  the  literature  a  series  of  131  cases.  It  occurs  much  more  commonly 
in  women,  and  especially  in  pregnant  or  puerperal  women,  than  in  men. 

In  the  131  cases  collected  by  Litzman  there  were  120  women  and 
only  11  men,  and  of  the  120  women,  85  were  pregnant  or  puerperal. 

Although  little  is  known  of  the  true  etiology  of  oesteomalacia,  it  seems 
to  be  due  to  unsanitary  modes  of  life,  lack  of  cleanliness,  poor  food,  etc. ; 
and  in  proportion  to  the  improved  sanitation  in  different  parts  of  the 
world,  the  disease  and  its  results  have  gradually  disappeared. 

The  disease  is  essentially  one  of  adult  life,  seldom  occurring  in  chil- 
dren, thus  differing  again  from  rachitis.  It  usually  effects  women  in  the 
active  child-bearing  age,  and  especially  those  who  have  borne  several 
children. 

Pathology. — Although  the  disease  may  aft'ect  any  portion  of  the  skele- 
ton, it  is  especially  apt  to  involve  the  pelvis  and  often  the  vertebree  and 
ribs.    The  exact  pathological  changes  have  not  been  definitely  settled. 

The  view  generally  accepted  for  years  held  that  the  condition  was 
simply  a  decalcification  of  the  bone  resulting  from  lactic  acid,  or  some 
similar  acid  circulating  in  the  blood.  Fehling,^  in  1888,  advanced  the 
theory  that  the  disease  was  a  trophoneurosis  due  to  some  abnormal 
conditions  in  the  ovaries. 

Although  the  improvement  in  the  disease,  which  often  follows  oophor- 
ectomy, would  seem  to  associate  osteomalacia  in  some  way  with  the 
ovarian  function,  the  exact  etiology  and  pathology  have  never  been 
settled. 

The  bone  in  a  marked  state  of  the  disease  is  very  soft  and  spongy  and 
on  section  shows  distinct  areolation.  Themarrow  spaces  are  dilated,  the 
vascularity  is  increased  and  the  normal  ossification  absent. 

The  pelvis  in  this  softened  state  is  unable  to  resist  the  pressure  of 
the  trunk  above,  the  counter-pressure  from  below,  and  the  traction  of  the 
various  muscles  and  ligaments,  and  actually  collapses. 

Distortion  of  the  Pelvis. — The  changes  in  the  shape  of  the  pelvis  vary 
with  the  extent  of  the  disease,  but  will  be  best  understood  by  considering 
the  typical  shape  in  a  well-marked  example  of  the  disease. 

Under  the  influence  of  the  body  weight  the  pliable  sacrum  is  rotated 
on  its  transverse  axis  and  the  promontory  driven  far  down  into  the  pelvic 
canal,  an  exaggeration  of  that  seen  in  the  rachitic  pelvis. 

The  apex  of  the  sacrum  and  the  coccyx  are  at  the  same  time  pulled 
markedly  forward  by  the  ligaments  and  muscles  attached  to  them,  thus 
causing  a  marked  anterior  flexion  in  the  sacrum  at  its  lower  third. 

The  force  from  below,  upward  and  inward  through  the  femora  pushes 
the  lateral  walls  of  the  pelvis  inward  (see  Fig.  397)  so  that  in  extreme 
cases  they  nearly  close  the  canal.  This  pushing  in  of  the  lateral  walls 
forces  the  pubic  rami  forward  giving  a  beak-shaped  projection  at  the 

1  Ueber    Kastration  bei  Osteomalacie,   Verl.  d.   deutschen  Gesellsch.  f.   Gj-n.,    1888,   ii, 
311-318. 
43 


674 


ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 


symphysis,  hence  the  name  "beak-shaped  pelvis"  sometimes  appHed 
to  one  deformed  by  osteomalacia.  The  tuberosities  and  rami  of  the 
ischia  are  also  approximated  so  that  in  extreme  cases  the  pubic  arch  is 
reduced  to  a  mere  slit. 

In  a  few  cases  where  the  patient  is  unable  to  stand,  long  sitting  upon 
the  softened  pelvis  will  cause  a  moderate  eversion  of  the  tubera  ischii. 
Thus  as  a  result  of  osteomalacia  the  pelvic  canal  may  be  distorted  into 
various  shapes  by  the  folding  in  upon  it  of  the  pelvic  walls,  this  distortion 
in  some  cases  amounting  almost  to  obliteration. 

Furthermore,  when  the  softening  process  involves  the  vertebrae  as  well 
as  the  pelvis,  the  weight  of  the  trunk  often  forces  the  lumbar  vertebrae 
downward  and  forward  into  the  pelvic  brim,  thus  still  further  tending 
to  close  the  canal. 


Fig.  397. — Osteomalacic  pelvis.      (Bunini.) 


Clinical  Picture. — The  history  of  a  patient  suffering  from  osteomalacia 
is  of  practical  importance.  The  patient  while  pregnant  first  notices 
rheumatoid  pains  in  various  parts  of  the  body,  perhaps  with  cramps  in 
certain  muscles  of  the  thighs  and  difficulty  in  walking.  A  little  later 
she  finds  that  her  spine,  ribs  and  especially  her  pelvis  are  sensitive  to 
pressure.  These  discomforts  continue  until  her  child  is  born  and  if,  as 
is  often  the  case,  she  has  had  previous  children,  this  labor,  as  compared 
with  the  others,  is  more  difficult.  After  the  birth  of  the  child,  her 
symptoms  gradually  disappear,  although  walking  may  be  difficult  for 
a  considerable  time.  At  her  next  pregnancy  the  symptoms  return  with 
increased  severity. 

The  rheumatoid  pains  are  more  intense  and  walking  is  very  difficult 
on  account  of  the  approximation  of  the  thighs  caused  by  the  collapse  of 
the  pelvis.  She  has  to  turn  through  nearly  a  half-circle  in  order  to  bring 
one  foot  in  front  of  the  other.  The  anterior  wall  of  the  pelvis  is  especially 
tender  on  pressure.    Walking  now  becomes  impossible  and  she  is  obliged 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      675 

to  spend  the  remainder  of  her  pregnancy  in  bed.  The  pelvis  in  the 
meantime  has  become  more  contracted,  so  that  labor  has  to  be  terminated 
by  craniotomy  or  Cesarean  section.  After  the  labor  the  symptoms 
again  gradually  disappear,  but  she  finds  that  she  has  lost  several  inches 
in  height.  This  results  from  the  bending  and  compression  of  the  bones 
of  the  spinal  column  with  their  descent  into  the  brim  of  the  pelvis.  This 
loss  in  stature  sometimes  amounts  to  a  foot  or  more. 

Diagnosis.^ — The  condition  of  osteomalacia  can,  as  a  rule,  be  readily 
determined  by  the  history  of  the  case,  and  a  physical  examination  of 
the  pelvis. 

History. — Rheumatoid  pains  beginning  during  the  pregnancy;  inability 
to  walk,  loss  in  stature. 

Physical  Examination.- — Pelvis  tender  on  pressure;  pliable,  distorted 
with  peculiar,  beak-like  process  in  front;  depressed  lateral  walls;  sharp 
anterior  flexion  of  sacrum;  marked  narrowing  of  the  pubic  arch;  approxi- 
mation of  coccyx  and  tubera  ischii. 

Influence  on  Labor. — ^The  deformity  of  the  pelvis,  produced  by  osteo- 
malacia, is  a  most  serious  one  and,  except  in  a  very  mild  type  of  the 
disease,  requires  Cesarean  section  for  the  delivery  of  a  living  child. 

Treatment. — This  may  be  considered  under  two  heads:  (a)  Prophyl- 
actic.   (6.)  Curative. 

Prophylactic. — As  the  disease  seems  to  be  largely  the  result  of  poor 
sanitation  and  poor  nutrition,  much  can  be  done  in  the  way  of  preven- 
tion by  attending  to  these  conditions.  The  effect  of  improved  sani- 
tation in  reduction  of  the  frequency  of  osteomalacia  has  already  been 
referred  to. 

Curative.- — If  a  patient  presents  the  early  symptoms  of  the  disease 
every  effort  should  be  made  to  improve  her  general  nutrition  by  nourish- 
ing food,  sleeping  out  of  doors,  the  administration  of  tonics  containing 
the  phosphates,  etc.- 

The  treatment  which  has  thus  far  proved  the  most  efficient  is  a  complete 
hysterectomy.  Although  the  reason  of  it  is  not  understood,  the  fact 
seems  to  have  been  demonstrated  that  the  cessation  of  the  function  of 
ovulation  and  the  so-called  "internal  secretion"  of  the  ovary  is  usually 
associated  with  a  marked  improvement  in  the  condition,  if  not  a  cure  of 
the  disease. 

New  Growths  of  the  Pelvis. — The  most  common  forms  of  pelvic 
tumors  are  exostoses,  bony  projections  which  may  occur  near  the  sacro- 
iliac joints,  upon  the  anterior  surface  of  the  sacrum  near  the  promon- 
tory, behind  the  symphysis  pubis,  or  perhaps  along  the  course  of  the 
iliopectineal  line. 

They  may  be  associated  with  multiple  exostoses  in  different  parts 
of  the  body  and  are  not  infrequently  found  in  patients  the  subject  of 
rachitis. 

The  bony  outgrowths  are  usually  not  large  and  cause  trouble,  not  so 
much  from  their  size  as  from  the  sharpness  of  their  projection,  exposing 
the  maternal  soft  parts  to  the  risk  of  contusion  or  perforation. 

The  author  met  with  one  case  in  which  a  sharp  pelvic  exostosis,  by 


G70        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

])ressure  (luring  the  labor  and  subsequent  sloughing,  produced  as  eom- 
jjlete  a  perforation  of  the  uterus  as  could  have  been  made  by  a  carpenter's 
punch.    The  forefinger  was  easily  passed  through  it. 

V^arious  other  tumors  may  arise  from  the  bony  pelvis  and  cause  partial 
or  complete  obstruction  to  labor;  among  them  may  l)e  mentioned 
cnchondromaia,  which  are  considered  the  most  frequent  variety;  fibro- 
mata, osteosarcomata,  and  carcinomata. 

The  author  has  met  with  2  cases  of  osteosarcoma  obstructing  the 
l)arturient  canal.  These  tumors  sometimes  become  cystic  and  assume 
rapid  growth. 

Tumors  of  the  pelvis  are  usually  inoperable,  and  their  influence  upon 
labor,  except  in  the  case  of  small  exostoses,  depends  largely  upon  their 
size.  Cesarean  section  is  the  method  by  which  the  labor  must  usually 
be  completed  in  order  to  obtain  a  living  child. 

Caries,  Necrosis,  Atrophy. — Deformity  of  the  pelvis  from  this  cause 
is  especially  seen  in  the  cases  of  tuberculosis  of  the  sacro-iliac  joint. 
If,  as  is  usually  the  case  in  tuberculous  bone  disease,  this  occurs  in  early 
life,  the  loss  of  bone  substance  followed  by  ankylosis  when  the  process 
heals,  leads  to  a  lack  of  de\elo]:)ment  of  the  afl'ected  side  of  the  pelvis, 
and  there  results  an  obliquely  contracted  pelvis  similar  to  that  of  Naegele. 
It  usually  presents  much  less  deformity  and  has  less  influence  in  causing 
dystocia  than  the  true  Naegele  pelvis,  due  to  the  faulty  development  in, 
or  absence  of,  the  sacral  ahe  on  one  side.  It  naturally  follows  that  the 
later  in  life  the  tuberculous  caries  and  ankylosis  occur  the  less  will  be 
the  pelvic  deformity  and  dystocia. 

Fracture  of  the  Pelvis. — Except  in  the  case  of  the  coccyx,  fracture  of 
the  pelvic  bones  is  usually  associated  with  injuries  so  severe  that  recovery 
therefrom  is  rare.  Hence  for  the  obstetrician  to  meet  with  a  pelvis 
deformed  by  a  previous  fracture  is  unusual.  Such  experiences,  however, 
do  occur. 

The  portion  of  the  pelvis  most  often  found  the  seat  of  fracture  is  the 
anterior  wall,  i.  e.,  the  pubes.    The  least  frequent  is  the  sacrum. 

The  deformity  of  the  pelvic  canal  depends  upon  the  location  of  the 
fracture,  and  may  be  due  to  the  following  conditions: 

(a)  The  distortion  of  the  pelvic  walls  at  the  point  of  union,  the  apposi- 
tion of  the  bones  being  imperfect. 

(6)  Excessive  callus.  This  is  especially  found  if  mobility  of  the  bones 
at  the  seat  of  fracture  persisted  for  a  considerable  time,  the  excessive 
callus  later  becoming  ossified  and  causing  marked  deformity. 

(c)  Ankylosis  of  joint  nearest  the  fracture.  Fracture  of  one  of  the 
ala?  of  the  sacrum  may  cause  in  union  an  ankylosis  of  the  sacro-iliac 
joint  on  that  side,  with  a  lack  of  development  or  an  atrophy  of  that  half 
of  the  pelvis  and  a  result  resembling  in  shape  and  effect  the  oblicpiely 
contracted  pelvis  of  Naegele. 

In  fracture  of  the  acetabulum,  the  result  of  hip-joint  disease,  the  head 
of  the  femur  may  project  into  the  i)elvic  ca\'ity  and  narrow  it  to  that 
extent. 

Fracture  of  the  pubes  causes  an  irregular  distortion  of  the  pelvic  inlet. 


ANOMALIES  OF  HARD   PARTS  OF  PARTURIENT  CANAL      677 

especially  if  the  accident  occurred  early  in  life  and  development  of  the 
affected  side  was  markedly  interfered  with. 

Fracture  of  the  loiver  part  of  the  sacrum  and  coccyx  is  followed  by  a 
dislocation  of  the  lower  fragment  forward.  This  often  unites  at  such 
an  angle  as  to  cause  a  sharp  projection  into  the  pelvic  canal  and  a  con- 
siderable dystocia. 

Fracture  of  the  coccyx  is  quite  a  common  accident  in  skating,  the 
feet  sliding  from  beneath  one  and  the  patient  suddenly  assuming  the 
sitting  posture  upon  the  ice.  The  coccyx  may  be  fractured  at  this  time, 
and  although  the  accident  may  be  followed  for  a  considerable  time  by 
pain  on  long  sitting,  especially  on  a  hard  seat,  the  pain  and  tenderness, 
as  a  rule,  gradually  disappear  and  there  only  remains  an  angulated  condi- 
tion of  the  coccyx  which  may  or  may  not  cause  dystocia  at  a  future 
labor. 

Occasionally  the  fractured  coccyx  is  a  source  of  annoyance  for  years, 
the  periosteum  becoming  inflamed  and  thickened  and  giving  rise  to  both 
local  and  reflex  disturbances.  This  will  be  found  discussed  under  the 
head  of  coccygodynia  in  different  works  on  gynecology. 

In  cases  of  dystocia,  caused  by  a  narrow  outlet,  the  coccyx  will  occasion- 
ally be  fractured,  or  a  separation  between  two  of  its  vertebrae  occur, 
especially  during  an  instrumental  delivery.  It  is  most  likely  to  occur  if 
there  has  been  a  previous  fracture  from  some  accident.  It  must  not 
be  thought  that  this  fracture  will  only  occur  in  a  forceps  delivery.  In 
one  case  the  author  attended  in  three  consecutive  labors.  In  the  first 
and  second  deliveries  which  were  rather  difficult  forceps  operations,  the 
snap  of  the  coccyx  was  felt  and  heard  as  traction  was  being  exerted  on 
the  instrument.  In  the  third  labor  the  patient  was  able  to  deliver  her- 
self without  the  use  of  instruments,  but  in  the  course  of  the  natural 
labor,  just  as  the  head  passed  the  pelvic  outlet,  the  snap  of  the  coccyx 
was  distinctly  heard. 

The  convalescence  from  fracture  of  the  coccyx  during  labor  is  similar 
to  that  from  a  fall  in  the  non-pregnant.  It  is  usually  necessary  for  com- 
fort that  the  patient  use  an  air-cushion  for  a  month  or  more  when  sitting 
for  any  length  of  time. 

It  may  be  stated  that  the  refracture  of  the  coccyx  may  be  considered 
a  happy  outcome,  as  it  is  one  of  the  simplest  means  of  overcoming  the 
difficulty.  The  reason  that  a  fractured  coccyx  does  not  easily  unite 
firmly  is  the  fact  that  each  act  of  defecation  brings  in  play  the  muscles 
attached  to  it  and  thus  prevents  the  immobility  necessary  for  the  best 
union. 

Anomalies  in  the  Articulations  of  the  Pelvic  Bones. 

Abnormally  Firm  Union. — Synostosis,  or  abnormally  firm  union  of  the 
pelvic  bones,  may  develop  in  any  of  the  pelvic  joints,  but  is  most  often 
found  at  the  symphysis  pubis  and  usually  occurs  in  early  life.  Although 
this  limits  the  slight  mobility  in  this  joint  normally  found  in  pregnancy 
and  labor,  if  no  other  pelvic  abnormality  is  present  it  is  of  little  impor- 


078        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

tauoe.  At  a  time  when  symphyseotomy  was  more  popular  and  more 
often  performed  than  now,  it  was  an  annoyance  to  find  that  the  separa- 
tion of  the  symphysis  required  a  saw  instead  of  a  knife,  as  expected.  Now 
that  pubiotomy  has  supphmted  symphyseotomy  whenever  any  division 
of  the  anterior  pelvic  wall  is  determined  upon,  a  saw  is  always  provided 
and  the  synostosis  of  the  symphysis  does  not  enter  into  consideration. 

Synostosis  at  the  Sacro-iliac  Joint. — Tlie  effect  of  synostosis  at  this 
joint  has  already  been  considered  under  two  phases:  (1)  From  faulty 
development  with  absence  of  the  sacral  ala?  on  one  side,  as  in  the  Naegele 
pelvis,  or  on  both  sides,  as  in  the  Robert  pelvis.  (2)  As  a  result  of  caries 
and  necrosis  in  tuberculous  disease  of  the  sacro-iliac  joint. 

In  all  cases,  except  where  the  synostosis  is  bilateral,  as  in  the  Robert 
pelvis,  the  abnormally  firm  union  at  the  sacro-iliac  joint  is,  as  a  rule, 
associated  with  atrophy  and  lack  of  development,  giving  an  obliquely 
contracted  pelvis  with  the  dystocia  common  to  the  pelvis  of  Naegele. 

Synostosis  at  the  Sacrococcygeal  Joint. — The  firm,  bony  union  of  the 
lower  coccygeal  vertebrse  normally  takes  place  during  the  latter  half  of 
the  child-bearing  age  of  women,  but  the  joints  between  the  sacrum  and 
coccyx  and  between  the  first  and  second  coccygeal  vertebrae  normally 
retain  their  mobility  until  the  child-bearing  age  is  over,  thus  allowing 
in  labor  a  recession  of  the  coccyx  and  an  increase  of  the  conjugate  at  the 
outlet  amounting  to  about  2  cm.  Occasionally,  as  a  result  of  injury  in 
youth  or  of  premature  calcification  in  later  life,  this  joint  becomes  anky- 
losed,  giving  rise  to  a  dystocia  similar  to  that  discussed  imder  Fracture 
of  the  Coccyx,  and  usually  dealt  with  in  the  same  way,  i.  e.,  by  fracture 
either  in  natural  or  instrumental  delivery. 

Abnormally  Loose  Union. — During  pregnancy  there  is  developed  in 
women  as  in  certain  animals  a  physiological  softening  and  relaxation 
of  the  pelvic  articulations  in  preparation  for  labor. 

This  relaxation  is  sometimes  increased  beyond  the  normal  so  that 
walking  is  difficult  and  painful.  The  increased  mobility  is  usually  due 
to  an  abnormal  development  of  synovial  fluid  within  the  joint,  but  could 
be  the  result  of  inflammation,  suppuration,  etc. 

A  marked  increase  of  fluid  within  the  joint  makes  rupture  of  the 
joint  more  likely  in  a  severe  instrumental  delivery. 

The  pain  and  difficulty  in  standing  and  walking  are  often  a  great 
annoyance  to  the  patient  who  demands  relief.  The  condition  osteomalacia 
must  be  thought  of,  although  rare.  With  this  excluded  the  patient's 
anxieties  should  be  quieted  and  relief  given,  as  far  as  possible,  by  a  well- 
fitting  corset  or  abdominal  binder  which  will  hold  the  pelvic  bones  in 
good  apposition  at  the  symphysis  pubis  and  the  sacro-iliac  joints. 

Anomalies  of  the  Pelvis  from  Disease  of  the  Spinal  Column. 

Spondylolisthesis.— The  spondylolisthetic  pelvis  (see  Fig.  398),  named 
and  described  by  Kilian,^  in  1853,  and  sometimes  called  Kilian's  pelvis, 

'  Dc  spondylolisthesi  gravissimiE  pclvangustise  causa  nuper  detecta,  Bonn,  185.3. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      679 


is  one  in  which,  as  the  translation  from  the  Greek  (vertebrae  slipping) 
indicates,  the  last  lumbar  vertebra  has  become  displaced  downward  on 
to  the  anterior  surface  of  the  sacrum. 

Varying  with  the  extent  of  the  disease,  the  lower  anterior  edge  of  the 
body  of  the  last  lumbar  vertebra  projects  beyond  the  anterior  surface 
of  the  sacrum,  or  the  lower  surface  of  this  last  lumbar  vertebra  has  slid 
down  so  as  to  lie  entirely  on  the  anterior  surface  of  the  upper  portion  of 
the  sacrum,  to  which  it  is  firmly  united  perhaps  by  bony  union. 

Along  with  this  dislocation  of  the  body  of  the  last  lumbar  vertebra 
there  follows  a  marked  lordosis  of  the  lumbar  spine  so  that  the  fourth, 
the  third  and,  in  extreme  cases,  even  the  second  lumbar  vertebra  has 
rolled  down  into  the  pelvic  brim,  shortening  the  stature  of  the  woman  and 

narrowing  the  conjugate  of  the 
pelvic  inlet  by  the  mass  of  the 
prolapsed  lumbar  spine. 

Although  we  owe  the  name  and 
the  first  accurate  description  to 
Kilian,  it  is  to  the  long  and  pains- 
taking work  of  Neugebauer, 
covering  a  number  of  years,  that 
we  owe  most  of  our  knowledge 


Fig. 


398. — Vertical  section  through  spondylo- 
listhetic pelvis.     (Kilian.) 


Fig.  399.  —  Last  lumbar  vertebra  of 
spondylolisthesis  (a),  contrasted  with  a 
normal  fifth  lumbar  vertebra.  (Neuge- 
bauer.) 


of  the  exact  pathological  condition  and  to  his  may  be  added  the  name 
of  Lane  who,  in  1885,  published  the  results  of  his  studies  of  the  changes 
produced  by  pressure  in  the  lower  part  of  the  spinal  column  and  called 
attention  to  the  fact  that  the  carrying  of  heavy  burdens  was  an  important 
etiological  factor  in  the  production  of  spondylolisthesis. 

It  is  only  the  body  of  the  last  lumbar  vertebra  which  is  displaced  down- 
ward and  forward,  the  inferior  articular  processes  retaining  their  normal 
relation  with  the  superior  articular  processes  of  the  first  sacral  vertebra 
and  the  arch  and  the  laminae,  as  a  rule,  maintaining  a  patent  spinal  canal 
so  that  the  cord  is  uninjured.  The  displacement  of  the  last  lumbar 
vertebra  is  due  then  to  a  stretching  and  bending  of  the  interarticular 
segment  (see  Fig.  399).  After  a  time,  as  a  result  of  friction  and  pressure, 
this  interarticukr  segment  may  present  a  transverse  fracture. 

Moreover,  the  pressure  and  friction  of  this  lumbar  vertebra  against 


680 


ABNORMAL  LABOR  FROM   AXOMALIES  IX  PASSAGES 


the  anterior  surface  of  the  sacruiii  may  also  cause  more  or  less  attrition 
here,  followed  l)y  ankylosis. 

The  descent  of  the  lumbar  vertebra'  into  the  pelvis  pushes  the  base 
of  the  sacrum  backward,  and  elevates  the  symphysis  and  anterior  portion 
of  the  pelvis.  This  diminishes  the  amount  of  the  pelvic  incHnation.  In 
fact,  in  extreme  cases  the  pelvic  inclination  may  be  entirely  obliterated. 

Etiology. — The  exact  etiology  of  spondylolisthesis  lias  never  been 
determined. 

Neugebauer  assigned  it  to  an  imperfect  development  of  the  inter- 
articular  segment  of  the  last  lumbar  \ertebra  or  to  its  fracture  with 
stretching  of  the  fibrous  union.  Lane,  on  the  other  hand,  having  seen 
several  examples  of  it  among  coal-heavers,  laid  stress  on  the  carrying  of 
heavy  weights  as  a  cause  of  the  deformity.    It  is  reasonable  to  suppose 


Fig.  4(A). — ]ilL■i:^ky's  case  of  spondylolisthesis.     (Hirst.) 


that  both  factors  enter  into  the  etiological  problem,  and  that  in  certain 
cases  both  are  concerned  in  the  result.  If  a  lumbar  vertebra  was  faulty 
in  the  development  of  its  interarticular  portion,  it  certainly  would  be 
more  likely  to  be  stretched  and  displaced  under  the  influence  of  a  heavy 
weight  than  one  normally  developed. 

Frequency. — The  condition  is  a  rare  one  but  Neugebauer,  in  1893, 
collected  from  the  literature  115  cases;  ^Yilliams,  in  1899,  collected  7 
more,  and  added  1  of  his  own.  Hirst,  in  1909,  reported  1  more,  making 
124  cases  on  record,  6.5  per  cent,  of  which  were  males. 

General  Appearance. — The  front  view  of  a  woman,  the  victim  of  spondy- 
lolisthesis (see  Fig.  400),  shortened  in  stature,  as  regards  her  trunk,  her 
thorax  approximated  to  her  pelvis,  as  though  her  ribs  fitted  within  the 
crests  of  the  ilia,  is  striking.  Her  external  generative  organs  are  tilted 
upward  so  that  the  vulva  is  directed  more  forward  than  normal.    A  deep 


ANOMALIES  OF  HARD   PARTS  OF  PARTURIENT  CANAL       681 

crease  is  sometimes  seen  extending  across  the  abdomen  above  the  s}'m- 
physis.  Viewed  from  behind,  as  a  result  of  the  lordosis  of  the  lower  lumbar 
spine,  the  posterior  superior  iliac  spines  and  the  iliac  crests  stand  out 
prominently  with  a  furrow  over  the  spinous  processes  of  the  lumbar 
vertebra?.  The  buttocks  are  flattened,  giving  the  gluteal  region  a  heart- 
shaped  appearance. 

Viewed  from  the  side,  the  woman  shows  the  hollow  back  incident  to 
the  lordosis,  and  in  some  cases  the  spine  of  the  last  lumbar  vertebra  stands 
out  very  prominently.  The  abdomen  is  more  or  less  pendulous,  even 
in  the  non-pregnant  state,  and  in  pregnancy  this  of  course  is  greatly 
exaggerated. 

This  is  easily  explained  in  the  non-pregnant  state  by  the  shortened 
abdomen,  and  the  exaggeration  during  the  latter  part  of  pregnancy  by 
the  failure  of  the  presenting  part  to  engage  on  account  of  the  obstructed 
pelvic  inlet  is  easily  understood. 

Diagnosis. — This  can  usually  be  made  by  careful  attention  to  the 
woman's  history;  her  general  appearance  and  careful  pelvimetry,  both 
external  and  internal.  It  may  be  possible  to  obtain  from  her  a  history 
of  serious  injury  which  might  have  associated  with  it  a  vertebral  fracture, 
or  she  may  give  a  history  of  severe  labor  and  burden  carrying.  Her 
general  appearance  of  shortened  trunk  and  abdomen  with  relatively 
long  legs  is  certainly  suggestive.  Her  gait  is  peculiar.  Her  toes  are  not 
turned  outward,  but  one  foot  is  swung  around  the  other  and  her  foot- 
prints lie  nearly  in  a  straight  line.  She  has  difficulty  in  balancing  herself 
and  tries  to  overcome  the  forward  tendency  of  her  body  by  carrying  her 
shoulders  far  back.  She  is  unable  to  carry  any  w^eight  in  front  of  her. 
Pelvimetry  shows  that  under  the  pressure  of  the  trunk  upon  the  anterior 
surface  of  the  sacrum  instead  of  its  base,  the  promontory  is  rotated  back- 
ward on  its  transverse  axis,  thus  narrowing  the  conjugate  at  the  outlet. 
Furthermore,  this  retroplacement  of  the  base  of  the  sacrum,  in  con- 
junction with  the  abnormal  strain  thrown  upon  the  iliofemoral  ligaments, 
causes  an  outward  rotation  of  the  innominate  bones  at  the  brim.  The 
result,  as  far  as  the  pelvic  bones  themselves  are  concerned,  is  a  funnel- 
shaped  pelvis.  At  the  inlet  the  transverse  diameters  between  spines  and 
crests  are  increased,  but  the  external  conjugate,  if  taken  just  below  the 
last  lumbar  spine,  is  usually  diminished,  although  if  taken  from  the  base 
of  the  sacrum  it  would  be  increased,  as  this  is  throwai  backward.  The 
transverse  and  conjugate  diameters  at  the  outlet  are  diminished  and  the 
pubic  arch  is  narrowed. 

On  internal  examination  the  conjugate  is  seen  to  be  narrowed.  This 
is  not  the  true  conjugate,  but  the  distance  between  the  symphysis  and 
the  body  of  one  of  the  lumbar  vertebrae  which  lies  in  front  of  the  sacrum. 

This  is  spoken  of  as  the  "false"  or  "effective"  or  "available"  conju- 
gate of  the  spondylolisthetic  pelvis  and  should  be  measured  to  the  nearest 
lumbar  vertebrie,  which  is  usually  the  fourth,  although  rarely  the  third, 
and  still  more  rarely  the  second.  The  fact  that  the  bony  projection  in 
the  pelvis  is  a  lumbar  vertebra  rather  than  a  sacral,  is  determined  by  the 
absence  of  transverse  processes,  and  the  fact  that  the  iliopectineal  line 


682        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

seems  to  be  continued  behind  the  projection  rather  than  ahnig  its  anterior 
surface. 

The  downward  displacement  of  the  lumbar  spine  carries  with  it  the 
large  vessels  of  the  lower  abdomen,  so  that  the  common  iliac  arteries 
and  even  the  bifurcation  of  the  aorta  can  sometimes  be  felt  on  vaginal 
examination. 

Influence  on  Labor. — ^In  mild  cases  the  influence  of  spondylolisthesis  on 
labor  is  similar  to  that  of  the  simple  flat  pelvis,  with  the  addition  of  a 
slight  contraction  of  the  outlet.  From  this  low  degree  of  deformity  in 
which  nature  may  perhaps  deliver  herself  unaided,  to  the  severe  type  of 
the  disease  in  which  the  pelvic  inlet  is  nearly  filled  with  lumbar  vertebrae 
and  the  outlet  greatly  contracted,  all  degrees  of  dystocia  present  them- 
selves. In  general  it  may  be  said  that  when  the  "available"  conjugate 
is  less  than  8  cm.,  Cesarean  section  is  usually  the  method  of  choice  in 
the  interest  of  both  mother  and  child. 

Prognosis. — The  statistics  of  mortality  in  spondylolisthesis  in  former 
years,  before  the  present  perfection  of  the  technic  of  Cesarean  section, 
should  not  be  taken  as  representing  the  prognosis  of  today,  when  more 
careful  pelvimetry  and  early  resort  to,  Cesarean  section,  before  the 
woman  is  exliausted  or  infected,  is  the  rule.  In  marked  cases  of  spondylo- 
listhesis the  prognosis  is  that  of  Cesarean  section.  It  is  in  the  lesser 
grades,  where  delivery  through  the  natural  passages  is  problematical, 
that  most  of  the  bad  results  are  obtained.  In  this  connection  a  few  facts 
may  well  be  considered. 

A  woman  with  spondylolisthesis  in  her  first  labor  may  succeed  in 
delivering  herself  unaided,  yet  in  a  subsequent  labor,  as  the  disease  is 
progressive,  the  dystocia  may  be  so  extreme  as  to  require  Cesarean 
section  for  the  delivery  of  a  living  child. 

Furthermore,  even  in  mild  grades  of  spondylolisthesis,  the  dystocia  is 
more  marked  with  the  same  grade  of  inlet  measurements  than  in  rachitis, 
for  the  reason  that  in  the  latter  the  pelvis  is  more  shallow,  and  the  outlet 
is  expanded  rather  than  contracted. 

Kyphosis. — Kyphosis,  or  hunch-back,  due  to  caries  of  the  spinal  column, 
produces  a  deformity  of  the  pehis  by  giving  an  abnormal  direction  to  the 
pressure  exerted  by  the  trunk  upon  the  base  of  the  sacrum. 

The  honor  of  first  accurately  describing  the  condition  is  properl}^ 
given  to  Breisky^  who,  in  1865,  published  an  article  on  "The  Influence  of 
Kyphosis  on  the  Shape  of  the  Pelvis."  This  honor,  however,  should 
be  shared  in  part  with  others,  especially  Rokitansky,  Litzmann,  and 
Neugebauer,  who  had  previously  recognized  it. 

Characteristics. — The  amount  of  pelvic  deformity  in  kyphosis  depends 
upon  the  situation  of  the  "hump"  and,  as  a  rule,  the  nearer  this  approaches 
the  sacrum  the  greater  the  deformity. 

If  the  hump  is  situated  high  enough  in  the  dorsal  region  (see  Figs. 
401  and  402),  the  compensating  lordosis  which  is  usually  present  may  be 
sufficient  to  maintain  the  normal  position  of  the  centre  of  gravity  and  no 

'  Ueber  deu  Einfluss  der  Kyphose  auf  die  Beckengestalt,  Zeitschr.  der  Gesellsch.  der 
Aerzte  in  Wien,  1865,  vol.  i. 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL     683 

Fig.  401 


Fi.^  40-' 


Figs   401  and  402.-Kyphosis  in  dorsal  region.    Mother  and  second  child  whose  weight  at 
birth  was  8  pounds  15  ounces.     Labor  spontaneous;  duration  five  and  a  half  hours. 


fiS4 


ABNORMAL   LABOR  FROM  AXOMALTES  IX  PASSAGES 


pehic  deformity  results.  If,  lioweNer,  the  kypliosis  is  situated  at  the 
jmictiou  of  the  dorsal  and  lumbar  portions  of  the  si)inal  column  (see 
Fig.  40^)),  or  esjH'cially  if  it  is  in  the  lumhosaeral  region  (see  Fig.  404) 
this  is  impossible  and  the  characteristic  deformity  results.  The  pressure 
of  the  trunk  comes  on  the  anterior  surface  of  the  sacrum.  The  sacrum 
is  rotated  on  its  transverse  axis,  so  that  its  base  is  displaced  backward  and 
its  apex  forward,  just  the  opposite  of  what  occurs  in  rachitis.  The  entire 
sacrum  is  narrowed  from  side  to  side  and  elongated. 


Fig.  403. 


-Kyphosis  at  junction  of  dorsal  and 
lumbar  regions. 


Fig.  404. — Kyphosis    in    lumbar 
region. 


^^  ith  the  posterior  displacement  of  the  sacral  base  there  occurs  a 
rotation  of  the  innominate  bones  on  their  anteroposterior  axis,  so  that 
the  iliac  crests  are  separated,  the  flaring  of  the  fossae  is  increased,  and  the 
tuberosities  of  the  ischia  are  apprf)ximated.  There  then  results  a  funnel- 
shaped  pelvis  with  enlarged  inlet  and  contracted  outlet. 

The  body  in  kyphosis  bends  forward  and  in  order  to  maintain  the 
normal  equilibrium  the  knees  of  the  patient  are  flexed  (see  F'ig.  404). 
The  pelvic  inclination  is  diminished.  When  the  kyphosis  occurs  at  the 
lumbosacral  junction  there  is  usually  caries  of  the  sacrum  as  well  as  of 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL     685 

the  lumbar  vertebra  and  ankylosis  taking  place  here  gi^es  a  most  marked 
deformity  resulting  from  kyphosis.  There  is  no  opportunity  for  a  com- 
pensating lordosis  below.  The  spine  above  bends  far  forward  and  the 
backward  displacement  of  the  base  of  the  sacrum  and  forward  displace- 
ment of  its  tip  give  the  extreme  funnel-shaped  kyphotic  pelvis.  This 
bending  downward  of  the  lumbar  spine  into  the  pelvic  inlet  gives  an 
obstruction  at  the  brim  somewhat  analogous  to  that  of  spondylolisthesis, 
and  was  described  by  Herrgott  as  spondylolizema.  It  is  distinguished 
from  it,  however,  in  occurring  as  a  result  of  caries  rather  than  from  faulty 
development  or  fracture. 

The  dipping  do^raward  of  the  lumbar  spine  into  the  brim  of  the  pelvis 
may  practically  occlude  the  pelvic  inlet  as  far  as  the  entrance  of  the  child 
is  concerned  and  this  condition  was  described  by  Fehling,^  iii  1S72,  as 
"pelvis  obtecta"  (see  Fig.  405). 


Fig.  405. — Pehds  obtecta.     (Fehling.) 


Frequency. — The  relative  frequency  with  which  one  sees  hump-backed 
women  on  the  streets  of  any  large  city  suggests  the  probability  of  any 
obstetrician  in  active  practice  having  to  deal  with  labor  in  a  pelvis 
deformed  by  this  condition.  At  the  Sloane  Hospital  for  Women  in  20,000 
consecutive  labors  there  were  15  kyphotic  pelves,  or  1  in  1333. 

This  is  a  greater  frequency  than  found  by  Klien^  in  his  statistical 
studies  (1  in  6016),  but  his  figures  were  thought  by  him  to  make  the 
condition  more  infrequent  than  actually  occurred. 

Influence  on  Pregnancy  and  Labor. — On  account  of  the  shortened  spine 
and  sinking  of  the  thorax,  the  abdomen  is  shortened  and  its  capacity 
diminished.  This  leads  to  a  pendulous  abdomen,  and  not  infrequently 
to  malpresentation  and  malposition  of  the  child,  as  transverse  presenta- 
tion and  occipitoposterior  position,  which  are  common. 

Furthermore,  when,  in  the  latter  part  of  pregnancy,  to  the  contracted 
thorax,  so  often  seen  in  the  hump-backed,  there  is  added  marked  upward 

1  Pelvis  Obtecta,  Archiv  f.  Gyn.,  1872,  iv,  1-.33. 

2  Die  Geburt  beim  kyphotischen  Becken,  Archiv  f.  Gyn.,  1896,  i,  1-12S. 


68(3        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

pressure  of  the  diaphragm  from  the  enlarging  uterus,  dyspnea  may  be 
a  distressing  symptom.  The  "hump"  itself,  on  account  of  the  increased 
abdominal  and  pelvic  weight,  may  become  sensitive  and  disturb  the 
patient's  sleep. 

Prognosis. — The  marked  picture  of  deformity  presented  by  many  of 
these  women,  the  subject  of  kyphosis,  with  their  shortened  stature, 
greatly  humped  back,  contracted  chest  and  pendulous  abdomen  may  at 
first  suggest  the  thought  that  nothing  short  of  a  Cesarean  section  will 
deliver  such  women;  and  yet  it  is  remarkable  how  many  will  deliver 
themselves  or  can  be  delivered  b\'  forceps  or  version  (see  Figs.  401 
and  402). 

In  the  15  cases  of  kyphosis  occurring  in  20,000  consecutive  deliveries 
at  the  Sloane  Hospital,  the  methods  of  delivery  were  as  follows:  normal, 
3;  by  forceps,  8;  by  version,  2;  by  Cesarean  section,  2,  In  this  group 
of  15  cases  there  was  no  maternal  mortality.  The  fetal  mortality  was 
3;  1  stillbirth  and  2  early  deaths,  all  premature.  The  stillbirth  was  in 
a  delivery  by  forceps;  the  2  early  deaths  occurred  in  children  delivered 
by  version. 

Unless  the  kyphosis  occurs  at  the  lumbosacral  junction  when  the 
prolapsed  vertebra  may  present  the  obstruction  similar  to  that  seen  in 
spondylolisthesis,  the  difficulty  in  labor  in  a  kyphotic  pelvis  is  usually 
not  encountered  until  the  floor  of  the  pelvis  is  reached. 

The  difficulties  then  are  usually  those  of  the  funnel  pelvis  and  must 
be  dealt  with  in  the  same  w^ay.  A  transverse  diameter  of  8  cm.  at  the 
pelvic  outlet  may  be  taken  as  the  practical  dividing  point  between  a 
delivery  which  may  be  expected  to  be  accomplished  through  the  natural 
passages,  either  spontaneously  or  by  the  use  of  the  forceps,  and  a  delivery 
whose  successful  termination  may  require  either  induction  of  premature 
labor  or  Cesarean  section,  or  some  operation  like  pubiotomy  which 
enlarges  the  pelvic  outlet.  In  pelves  contracted  at  the  outlet  the  author 
believes  that  version  is  not  a  good  method  of  delivery,  as  on  account  of 
the  delay  in  delivering  the  after-coming  head,  the  child  is  not  infrequently 
lost. 

Surprises  frequently  occur  and  many  cases  with  a  transverse  diameter 
of  8  cm.  by  marked  molding  of  the  fetal  head  under  the  influence  of 
strong  pains  will  deliver  themselves,  but  to  regard  the  abo\-e  diameter 
mth  suspicion  may  be  looked  upon  as  a  good  practical  working  rule. 

The  author's  experience  leads  him  to  believe  that  a  transverse  diameter 
of  7  cm.  or  less  at  the  outlet  should  be  regarded  as  an  indication  for 
Cesarean  section. 

Scoliosis. — ^A  certain  amount  of  lateral  curvature  of  the  spine  is  fre- 
quently seen  in  young  women  who  habitually  sit  in  an  improper  atti- 
tude at  the  table  or  desk,  especially  during  their  developmental  period. 
This,  however,  is  usually  slight,  is  situated  at  the  upper  part  of  the  spinal 
column  and  is  usually  compensated  for  by  a  similar  curve  in  the  opposite 
direction  lower  down  and  has,  as  a  rule,  little  if  any  effect  upon  the  shape 
of  the  pelvis. 

When  the  lateral  curxature  is  situated  in  the  lumbar  region,  it  is[usually 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      687 

associated  with  a  pelvis  contracted  in  one  of  its  oblique  diameters,  but 
usually  not  sufficient  to  cause  dystocia. 

Marked  scoliosis,  however,  is  usually  of  rachitic  origin  and  is  charac- 
terized by  a  typical  deformity  of  the  pelvis  properly  called  scoliorachitic 
(see  Fig.  406). 

The  innominate  bone  toward  which  the  convexity  of  the  lumbar  spine 
is  directed  receives  the  greater  part  of  the  weight  of  the  trunk  from  above 
and  upward  pressure  through  the  femur,  and  under  this  unequal  pressure 
one  side  of  the  pelvis  is  pushed  inward,  giving  an  oblique  contraction. 

The  innominate  bone  on  the  affected  side  is  pushed  upward,  inward 
and  backward,  displacing  the  acetabulum  anteriorly  and  pushing  the 


Fig.  406. — Scoliorachitic  pelvis.      (Tarnier.j 

symphysis  to  the  opposite  side.  In  this  condition  there  are  present  the 
results  of  rachitis  as  well  as  those  of  the  spinal  curvature,  henqe  there  is 
usually  more  or  less  contraction  of  the  inlet  due  to  the  rotation  of  the 
sacrum  on  its  transverse  axis  and  an  enlargement  of  the  outlet  due  to  an 
e version  of  the  tubera  ischii. 

Thus,  while  the  pelvis  is  obliquely  contracted  and  occasionally  anky- 
losis occurs  at  the  sacro-iliac  joint  on  the  affected  side,  it  differs  from 
the  obliquely  contracted  pelvis  of  Naegele  in  that  in  the  scoliorachitic 
pelvis  the  outlet  is  enlarged,  while  in  the  Naegele  pelvis  it  is  contracted. 

Diagnosis. — The  condition  is  usually  detected  without  difficulty  by 
inspection  of  the  spinal  curvature  and  by  careful  pelvimetry.  If  unnoticed 
before,  the  spinal  curvature  when  at  all  marked  is  usually  detected  when 


688 


ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 


the  lumbosacral  region  is  exposed  for  measuring  the  oblique  diameters 
in  the  course  of  routine  pelvimetry.  The  pelvimeter  shows  a  marked 
difference  in  the  two  oblique  diameters  and  careful  palpation,  both 
internal  and  external  shows  the  characteristics  of  an  obliquely  contracted 
pelvis,  the  curve  of  the  pelvic  cavity  on  the  affected  side  more  or  less 
flattened,  the  symphysis  displaced  to  the  opposite  side,  but  in  this  case, 
on  account  of  the  rachitic  origin,  the  pubic  arch  and  pelvic  outlet  enlarged. 


Fig.  407. — Kyphoscoliosis. 


Influence  on  Labor. — x\lthough  minor  grades  of  scoliosis  may  exist 
without  affecting  the  pelvis  enough  to  cause  dystocia,  in  the  typical 
scoliorachitic  pelvis  only  one  oblique  diameter  is  available  for  the  long 
diameters  of  the  presenting  part,  and  the  amount  of  dystocia  depends  upon 
the  amount  of  contraction  in  this  diameter.  After  the  inlet  is  passed, 
the  labor  usually  progresses  favorably  on  account  of  the  expanded  outlet. 

As  a  rule  the  dystocia  is  not  so  extreme  that  it  cannot  be  overcome  by 
the  use  of  the  forceps. 

Kyphoscoliosis. — The  kyphoscoliotic  pelvis  (see  Fig.  407)  combines 
the  features  of  the  two  pelvic  deformities  just  described.     The  disease 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL      689 

is  usually  rachitic  in  origin,  and  rachitic  kyphosis  being  usually  situated 
high  in  the  dorsal  region  may  be  largely  compensated  for  by  a  lumbar 
lordosis.  The  exact  type  of  pelvic  deformity  will  depend  upon  which  of 
the  two  conditions,  the  kyphosis  or  the  scoliosis,  predominates.  As  a 
rule,  however,  the  contraction  of  the  inlet  usually  found  in  the  typical 
scoliotic  pelvis  is  lessened  by  the  kyphosis  and  the  contraction  of  the 
outlet  usually  associated  with  kyphosis  is  lessened  by  the  scoliosis. 

Diagnosis. — The  diagnosis  is  made  by  general  inspection,  careful  pelvim- 
etry, and  pelvic  palpation.  All  degrees  of  dystocia  may  be  met  with 
and  must  be  dealt  with  according  to  the  amount  of  pelvic  contraction. 

Lordosis. — Lordosis,  or  anterior  curvature  of  the        

spinal  column  associated  with  other  spinal  or  pelvic 
disease,  is  not  at  all  uncommon  and  has  frequently 
been  referred  to  in  our  study  of  pelvic  deformities. 
As  a  primary  condition  and  unconnected  with  spinal 
and  pelvic  disease  it  is  very  rare.  Hirst,  however, 
in  his  text-book  of  Obstetrics,  describes  and  pic- 
tures a  case  of  his  (see  Fig.  408)  resulting  from 
paralysis  of  the  spinal  muscles  and  calls  attention 
to  the  increased  pelvic  inclination  and  possible  diffi- 
culties in  coition  and  parturition.  The  engagement 
of  the  presenting  part  may  be  seriously  interfered 
with,  although  there  are  not  a  sufficient  number  of 
cases  on  record  to  give  much  practical  experience 
with  this  condition. 

Anomalies  Resulting  from  Abnormalities  of 
THE  Subjacent  Skeleton. 

For  the  development  and  maintenance  of  the 
normal  shape  of  the  pelvis  it  is  necessary  to  have 
an  equal  amount  of  force  transmitted  to  the  pelvis 
through  each  femur,  whether  it  be  simultaneously, 
as  in  standing,  or  alternately,  as  in  walking  or 
running.  tp      .^„       t    ^    • 

'=>  IIP'-  ...  Fici-  408.  —  Lordosis 

in  studymg  the  deformities  of  the  pelvis,  it  is  from  paralysis  of  spinal 
seen  that  whenever  this  force  is  unequal  on  the  muscles.  (Hirst.) 
two  sides,  there  is  apt  to  result  an  oblique  contrac- 
tion of  the  pelvis,  more  marked  if  it  is  exerted  during  early  childhood 
while  the  pelvis  is  in  its  formative  period.  This  inequality  of  force  is 
seen  in  any  lameness  in  which  on  account  of  pain  or  weakness  in  one  of 
the  lower  limbs  the  weight  of  the  body  is  transferred  as  soon  as  possible 
to  the  other.  This  application  of  an  abnormal  amount  of  force  to  the 
sound  side  of  the  pelvis  usually  results  in  pushing  it  upward,  inward,  and 
backward. 

A  certain  amount  of  pelvic  distortion  sometimes  results  from  bilateral 
lameness,  but  is  usually  of  little  importance  in  obstetrics. 

The  most  common  causes  of  unilateral  lameness  causing  pelvic  deformity 
44 


690        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

are  coxitis,  dislocation  of  the  femur,  and  deformity  or  absence  of  one  of 
the  lower  extremities. 


Fig.  409.— Coxalgic  pelvis  before  patient  has  walked.     (Redrawn  from  Williams.) 

Coxitis. — The  coxalgic  pelvis,  or  one  resulting  from  hip-joint  disease, 
is  an  obliquely  contracted  pelvis,  but  its  exact  shape  depends  upon  the 
age  of  the  individual  at  which  the  disease  was  an  active  process  (see 
Figs.  409  and  410). 


Fig.  410. — Coxalgic  pelvis  after  patient  has  walked.      (Redrawn  from  '\\illiams.) 

If  the  disease  is  active  before  the  child  begins  to  walk,  or  if  the 
child  is  confined  to  the  bed  for  a  long  time,  there  is  a  lack  of  development 
on  the  affected  side,  so  that  the  whole  innominate  bone  of  that  side  is 
smaller  than  normal,  the  sacral  ala  of  that  side  is  underdeveloped,  and 


ANOMALIES  OF  HARD  PARTS  OF  PARTURIENT  CANAL     691 

often  there  is  an  ankylosis  of  the  sacro-ihac  joint  locating  the  deformity, 
chiefly  on  the  affected  side. 

On  the  other  hand,  if  the  disease  develops  later,  the  pelvic  deformity 
may  be  most  marked  on  the  healthy  side  and  result  from  the  weight 
of  the  body  being  thrown  chiefly  onto  the  healthy  limb  and  the  greater 
pressure  on  the  sound  side  of  the  pelvis  pushing  this  innominate  bone 
upward,  inward,  and  backward,  and  thus  causing  the  deformity  on  the 
healthy  side. 

In  both  cases,  however,  there  is  seen  to  be  an  oblique  contraction. 
At  the  same  time  the  pelvis  is  usually  tilted,  being  higher  on  the  healthy 
side.  The  dystocia  is  usually  less  in  this  latter  variety  than  in  the  former, 
where  the  lack  of  development  is  more  marked. 

Diagnosis.- — The  presence  of  a  coxalgic  pelvis  is  usually  suggested 
by  the  lameness  of  the  patient  and  is  verified  by  pelvimetry  and  careful 
external  and  internal  palpation  of  the  pelvis  and  hip-joints.  The  fixation 
of  the  thigh  often  proves  a  distinct  annoyance  in  delivery  by  forceps,  and 
for  that  reason  version  is  sometimes  preferred. 

Influence  on  Labor.— The  effect  of  the  coxalgic  pelvis  on  labor  is  that 
of  an  obliquely  contracted  pelvis.  Of  the  two  varieties  of  coxalgic 
deformity,  that  which  results  from  the  disease  occurring  in  very  early 
life  gives  the  most  marked  deformity  and  may  be  similar  to  that  of  the 
Naegele  pelvis.  As  a  rule,  however,  the  amount  of  pelvic  deformity  is 
not  sufficient  to  require  Cesarean  section  and  the  dystocia  can  usually 
be  overcome  by  the  use  of  forceps  or  version. 

Dislocation  of  the  Femur  or  Femora. — The  dislocation  of  the  head 
of  the  femur  may  be  congenital  or  acquired  in  youth  and  never  reduced. 
Furthermore,  the  condition  may  be  unilateral  or  bilateral,  usually  the 
former.  Whether  the  dislocation  is  unilateral  or  bilateral,  the  pelvic 
deformity  is  usually  not  sufficient  to  cause  marked  dystocia. 

In  unilateral  dislocation  the  shape  of  the  pelvis  depends  upon  the 
direction  taken  by  the  head  of  the  femur.  If  it  is  displaced  upward  and 
backward,  as  is  usually  the  case,  the  corresponding  leg  is  shortened  and 
the  greater  weight  is  thro^^^l  on  the  leg  of  the  sound  side,  with  a  tendency 
to  push  that  side  of  the  pelvis  upward,  inward,  and  backward,  and  to  tilt 
that  side  of  the  pelvis  upward.  If  the  displacement  of  the  head  of  the 
femur  is  forward,  there  is  a  tendency  to  push  the  anterior  wall  of  that 
side  of  the  pelvis  inward.  In  both  of  these  instances  there  results  more 
or  less  oblique  contraction  of  the  pelvis.  If  there  is  a  congenital  disloca- 
tion of  the  heads  of  both  femora  upward  and  backward  onto  the  iliac 
bones  there  occurs  an  interesting  change  in  the  shape  of  the  pelvis, 
although  usually  not  sufficient  to  cause  dystocia.  The  sacrum  is  rotated 
forward  with  absence  of  pressure  through  the  femora  on  the  lateral  walls 
of  the  pelvis  and  by  the  pull  of  the  muscles  attached  to  pelvis  and  femora, 
the  ischia  are  separated,  especially  at  their  tuberosities.  There  results 
a  pelvis  moderately  flattened,  but  with  transverse  diameter  increased, 
especially  at  the  outlet,  and  with  cavity  shallow.  On  inspection  and 
palpation  the  trochanters  are  found  more  prominent,  the  buttocks  are 
broader  and  on  side  view  the  patient  shows  a  distinctly  hollow  back. 


692         ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

On  account  of  the  imperfection  of  the  false  acetabula,  there  is  apt  to 
be  more  or  less  waddling  in  the  gait. 

Absence  or  Deformity  of  One  or  Both  Lower  Extremities. — ^In  the 
absence  of  one  lower  extremity  the  weight  of  the  body  is  of  necessity 
upon  the  sound  leg,  this  has  the  effect,  previously  noted,  of  pushing  the 
sound  side  of  the  pelvis  upward,  inward,  and  backward,  and  giving  as  a 
result  an  obliquely  contracted  pelvis,  usually,  however,  not  sufficient  to 
cause  marked  dystocia. 

The  result  produced  by  the  absence  of  one  lower  extremity  may  be 
produced  in  a  lesser  degree  by  any  deformity  of  one  lower  extremity  which, 
although  doing  some  work,  is  unable  to  do  its  full  share. 

This  applies  to  the  atrophied  limb  of  anterior  poliomyelitis,  but  in 
this  case  there  may  be  added  the  faulty  development  of  the  pelvis  on  the 
affected  side.    Even  here,  however,  marked  dystocia  is  unusual. 

In  the  absence  of  both  lower  extremities  the  patient  is  obliged  to  spend 
much  of  the  time  in  the  sitting  posture  giving  the  so-called  "sitz  pelvis  " 
in  which  the  tuberosities  of  the  ischia  are  everted,  the  pelvis  made  more 
shallow,  and  the  crests  of  the  ilia  approximated. 

In  bilateral  club-foot  a  change  in  the  pelvis  has  been  noted  as  a  result 
of  the  absence  of  spring,  as  compared  with  that  of  the  normal  person  who 
possesses  a  normal  arch  of  the  foot  and  walks  with  more  or  less  flexion 
of  the  knees.  The  resulting  pelvis  is  one  with  contracted  outlet  and 
increased  inclination,  but  usually  of  very  little  obstetric  importance. 

INFLUENCE    OF   CONTRACTED   PELVIS    ON   PREGNANCY. 

While  studying  the  different  varieties  of  deformity  of  the  pelvis  it 
may  be  well  to  consider  the  influence  of  a  contracted  pelvis  on  pregnancy 
and  labor  as  contrasted  with  these  processes  in  a  normal  parturient  canal. 

As  regards  pregnancy,  it  is  in  contraction  of  the  pelvic  inlet  that  depar- 
tures from  the  normal  are  especially  seen.  In  the  early  months,  while 
the  uterus  is  in  the  pelvis,  a  contracted  inlet  is  inclined  to  interfere  with 
the  normal  rising  of  the  uterus  in  its  growth.  If  there  has  been  a  previous 
tendency  to  retroversion,  this  tendency  is  exaggerated,  and  to  this  the 
tendency  to  incarceration  is  added,  with  its  associated  symptoms  of 
vesical  retention  and  rectal  pressure. 

With  these  tendencies  overcome  and  the  pregnancy  advanced  to  the 
later  months  there  are  certain  distinct  characteristics  of  pregnancy  asso- 
ciated with  a  pelvis  contracted  at  the  inlet. 

As  the  fetus  approaches  maturity  and  the  head  becomes  too  large  to 
enter  the  brim  of  the  pelvis,  the  uterus  as  a  whole  becomes  lifted  out  of 
the  pelvis  and  more  protrusion  of  the  uterine  and  abdominal  walls  results. 
This  forward  protrusion  is  most  marked  when  the  abdomen  is  shortened 
by  disease  of  the  spinal  column,  but  is  present  to  a  certain  extent  even 
with  normal  spinal  column  when  the  inlet  is  contracted.  Moreover,  if 
the  patient  is  a  multigravida,  with  uterine  and  abdominal  walls  previously 
stretched,  this  forward  protrusion  is  favored,  giving  a  pendulous  abdomen 
with  a  tendency  to  faulty  presentations,  prolapse  of  the  cord,  etc,     . 


INFLUENCE  OF  CONTRACTED  PELVIS  ON  PREGNANCY      693 

Pendulous  Abdomen. — On  account  of  lack  of  support  in  the  anterior 
abdominal  wall,  even  with  a  normal  pelvis,  the  uterus  sometimes  falls 
far  forward  and  has  to  be  assisted  in  the  engagement  of  the  presenting  part. 

If  the  pelvic  inlet  is  contracted,  a  pendulous  abdomen  is  much  more 
common  and  the  uterus,  instead  of  being  inclined  at  an  angle  of  35 
degrees  to  the  horizon,  may  lie  horizontally  or  may  fall  far  forward 
and  downward  so  that  the  fundus  lies  below  the  level  of  the  cervix. 

Faulty  Presentations. — In  a  contracted  inlet,  especially  with  a  narrow 
conjugate,  the  head  being  prevented  from  engaging,  is  apt  to  slide  into 
one  of  the  iliac  fossae  giving  rise  to  a  transverse  or  shoulder  presenta- 
tion. A  lesser  degree  of  the  lateral  displacement  of  the  presenting  part 
will  give  an  oblique  presentation.  The  contracted  inlet,  preventing  the 
ready  entrance  of  the  vertex  and  normal  flexion,  may  favor  extension 
of  the  head  and  result  in  a  brow  or  face  presentation. 

Prolapse  of  the  Cord. — In  any  case  in  which  the  presenting  part  does 
not  readily  engage  and  accurately  fit  the  pelvic  inlet,  a  loop  of  cord  is 
apt  to  slip  down  in  advance,  hence  it  is  in  deformed  pelves  that  prolapse 
of  the  cord  is  so  common.  This  is  of  much  less  consequence  during  preg- 
nancy and  before  the  rupture  of  the  membranes,  than  during  labor  and 
after  the  membranes  have  ruptured,  but  it  is  important  at  any  time  that 
the  possibility  of  prolapse  of  the  cord  in  connection  with  a  contracted 
pelvis  should  be  thought  of,  watched  for,  and  if  detected,  replaced  as 
soon  as  possible. 

Influence  on  Labor. — There  are  certain  general  characteristics  of  labor 
in  a  contracted  pelvis  which  should  be  considered  before  the  means  for 
dealing  with  the  dystocia  are  studied. 

In  the  first  place,  when  the  amount  of  pelvic  contraction  is  not  too  great 
to  permit  of  delivery  through  the  natural  passages,  much  depends  upon 
the  race,  the  character  of  the  pains,  and  the  size  and  moldability  of  the 
fetal  head. 

Race. — It  is  the  experience  of  practically  all  obstetricians  who  have 
to  deal  with  labor  in  both  black  and  white  women,  that  with  a  given 
amount  of  pelvic  contraction,  about  twice  as  many  black  women  as  white 
will  succeed  in  delivering  themselves.  This  is  largely  due  to  the  smaller 
size  and  greater  moldability  of  the  head  of  the  colored  child,  as  will  be 
considered  later. 

Character  of  the  Pains. — In  obstetrics  nothing  is  more  difficult  to 
prognosticate  than  the  character  and  efficiency  of  the  pains  of  a  primi- 
gravida.  A  pelvic  canal,  known  by  careful  pelvimetry  and  palpation  to 
be  perfectly  passable  for  a  given  head  under  normal  strong  uterine  con- 
tractions, becomes  absolutely  impassable  without  artificial  aid  in  the 
case  of  a  woman  who  becomes  nervously  exhausted  in  the  first  stage  of 
labor,  and  becoming  discouraged  and  losing  self-control,  will  not  or  can- 
not use  her  voluntary  muscles  in  the  second  stage.  On  the  other  hand, 
a  woman  with  placid  disposition,  good  physique,  cheerful,  hopeful  and 
helpful  to  the  last,  will  make  the  most  and  best  of  her  pains,  will  mold 
the  fetal  head  and  deliver  her  child  perhaps  unaided.  In  some  multi- 
gravidse,  however,  stretching  and  weakening  of  the  uterine  and  abdom- 


094        ABNORMAL  LABOR  FROM  ANOMALIES  IN  PASSAGES 

inal  walls,  due  to  a  previous  difficult  labor,  make  a  certain  amount  of 
uterine  inertia  inevitable,  in  spite  of  the  will  of  the  woman. 

Size  and  Moldahiliti/  of  ihe  Fetal  Head. — The  difficulty  in  accurately 
determining  the  size  of  the  fetal  head  and  the  advances  made  in  this 
direction  have  already  been  discussed  (see  page  189).  Another  uncertain 
factor  in  the  problem  is  its  moldability.  Reference  has  already  been 
made  to  heads  of  colored  children  and  to  the  fact  that  their  smaller  size 
and  greater  moldability  will  often  enable  them  to  pass  a  narrowed 
canal  which  in  the  case  of  the  white  child  might  be  impassable.  ^Nlore- 
over,  the  heads  of  certain  white  children  with  thin  cranial  bones,  wide 
sutures  and  large  fontanelles,  perhaps  premature,  will  mold  with  great 
ease  and  will  pass  through  a  canal  which  for  a  hard  unmoldable  head 
would  be  impossible.  Another  characteristic  of  labor  in  a  contracted 
pelvis  is  the  disturbance  in  the  normal  process  of  dilatation  of  the  cervix. 
Instead  of  the  head  lying  low  in  the  pelvis  and  in  close  contact  with  a 
partially  retracted  cervix  in  the  first  stage  of  labor,  in  a  pelvis  with  con- 
tracted inlet  the  head  usually  lies  high.  The  force  of  the  uterine  contrac- 
tion acts  on  the  entire  column  of  liquor  amnii,  and  the  amniotic  sac 
forced  down  into  the  cervical  canal  usually  ruptures  prematurely,  before 
the  cervix  is  dilated  and  retracted,  and  the  labor  has  to  continue  without 
the  ball-valve  action  of  the  head  to  hold  back  a  large  part  of  the  liquor 
amnii  and  to  immediately  aid  with  its  solid  wedge  in  the  rapid  dilatation 
of  the  cervix.  After  the  premature  rupture  of  the  membranes  in  a  pelvis 
with  contracted  inlet,  the  first  stage  is  apt  to  be  tedious,  as  it  has  to  be 
accomplished  by  a  gradual  molding  of  the  head  and  retraction  of  the 
cervix  under  uterine  contractions  which  may  not  be  efficient. 

Prognosis. — The  dangers  of  labor  in  a  contracted  pelvis  may  be  either 
maternal  or  fetal. 

The  Matermd  Dangers. — These  vary  indefinitely  with  the  surround- 
ings and  care  of  the  patient  and  whether  she  is  under  careful  observation 
and  skilled  care  in  a  well-regulated  maternity  hospital  or  whether  she 
is  under  the  care  of  a  man  who  never  practises  pelvimetry  and  seldom 
examines  his  cases  until  they  are  in  labor. 

At  the  Sloane  Hospital,  in  a  consecutive  series  of  20,000  deliveries 
there  were  1770  cases  of  deformed  pelvis,  and  in  this  series  35  mothers 
were  lost,  making  a  maternal  mortality  of  1.9  per  cent.  This  is  only 
slightly  above  the  total  maternal  mortality  of  the  hospital,  which  is 
1.09  per  cent.  Williams,  in  a  series  of  278  cases  of  labor  with  contracted 
pelvis,  reports  a  maternal  mortality  of  2.88  per  cent. 

Maternal  mortality  and  morbidity  resulting  from  labor  in  a  contracted 
pelvis  are  easy  to  understand,  when  it  is  considered  first  of  all  that,  as 
a  rule,  the  membranes  rupture  early  and  the  labor  is  prolonged.  It  is 
the  common  experience  of  obstetricians  that  a  long,  dry  labor,  with  its 
accompanying  lowered  vitality  of  the  soft  parts  of  the  parturient  canal 
and  tendency-  to  putrefaction  in  the  amniotic  sac,  predisposes  to  infection 
in  any  labor,  especially  if,  as  in  a  contracted  pelvis,  the  labor  has  to  be 
terminated  by  artificial  measures.  Hence  infection  may  be  looked  upon 
asoneof  the  chief  dangers  to  themotherfrom  labor  with  a  contracted  pelvis. 


INFLUENCE  OF  CONTRACTED  PELVIS  ON  LABOR  695 

Another  danger  which  should  always  be  thought  of,  is  rwpture  of  the 
uterus.  In  pelves  of  moderate  contraction,  especially  in  primigravidse, 
it  is  a  common  rule,  and  within  limitations  a  good  one,  to  wait  and  see 
what  nature  can  do  toward  accomplishing  the  delivery.  During  this 
period  of  waiting  and  observation,  however,  the  fact  must  not  be  lost 
sight  of  that  the  uterus,  working  against  an  obstacle  which  may  be  too 
great  for  it  to  overcome,  is  gradually  thinning  its  lower  segment,  and  if 
this  process  is  allowed  to  continue  too  long,  either  spontaneous  rupture 
may  occur,  or  the  operative  interference  necessary  for  the  termination 
of  the  labor  may  cause  a  rupture.  The  great  danger  of  causing  a  rupture 
by  version  or  attempted  version,  in  a  tonic  uterus,  where  the  liquor 
amnii  has  drained  away  and  the  uterus  has  contracted  on  the  child,  is 
discussed  elsewhere  (see  page  710). 

Another  danger  to  which  the  mother  is  subjected  in  labor  with  con- 
tracted pelvis  is  sloughing  and  fistidoe. 

Fortunately  for  parturient  women  the  dangers  of  long  pressure  of  the 
fetal  head  upon  the  soft  parts  of  the  pelvic  canal  and  neighboring  organs 
have  become  well  known,  and  by  avoidance  their  results,  such  as  vesico- 
vaginal and  rectovaginal  fistulse,  are  much  less  commonly  seen  than 
formerly. 

As  a  rule  it  is  the  presenting  fetal  head,  which  by  long  compression  of 
the  soft  parts  between  itself  and  the  hard,  bony  pelvis,  causes  the  slough 
and  subsequent  fistula.  The  fetal  body  is  usually  too  soft  and  compres- 
sible to  cause  this  result  and  the  after-coming  head  usually  does  not 
remain  long  enough  in  the  pelvis. 

Emphasis  upon  the  liability  of  long  pressure  to  cause  fistulse  by  slough- 
ing does  not  exclude  the  possibility  of  the  production  of  fistulse  by  the 
forceps  in  delivery. 

One  more  maternal  danger  from  labor  in  a  contracted  pelvis  will  be 
mentioned,  and  that  is  hemorrhage.  The  long,  tedious  labor  is  very  apt 
to  result  in  an  exhausted  uterus  as  well  as  an  exhausted  mother,  and  an 
exhausted  uterus  does  not  readily  contract  or  maintain  its  contraction 
after  labor.  This  means  a  tendency  to  postpartum  hemorrhage  with 
its  own  immediate  dangers  and  the  subsequent  liability  to  infection  from 
lowered  vitality,  retained  blood-clots,  etc. 

Fetal  Bangers. — In  the  1770  cases  of  labor  in  contracted  pelvis  at  the 
Sloane  Hospital  there  were  225  stillbirths;  129  died  subsequently 
before  the  mothers  left  the  hospital,  and  there  were  37  abortions.  This 
gave  a  total  infant  mortality,  excluding  the  abortions,  of  20  per  cent. 
It  is  only  fair  to  state,  however,  that  during  the  first  half  of  this  series. 
Cesarean  section  was  scarcely  ever  performed  and  craniotomy  was  the 
rule  when  the  forceps  or  version  failed.  Williams,  in  his  series  of  278 
cases,  reports  an  infant  mortality  of  12.96  per  cent. 

Some  of  the  causes  of  this  fetal  mortality  will  now  be  considered. 
For  a  long  time  it  has  been  held  that  as  long  as  the  membranes  remain 
unruptured,  labor  may  continue  indefinitely  in  the  first  stage  with  scarcely 
any  danger  to  the  child.  The  writer  desires  to  call  attention  to  the  fact 
that  there  are  many  exceptions  to  this  rule,  and  that  he  has  many  times 


G96         ABXORMAL  LABOR  FROM  ANOMALIES  IX  PASSAGES 

met  with,  cases  in  wliicli,  although  the  membranes  were  unruptured,  he 
has  foimd,  on  dehvery  by  Cesarean  section,  a  decided  caput  formed,  the 
meconium  in  the  Hquor  amnii  and  the  fetal  heart  showing  an  undue 
amount  of  embarrassment  from  compression. 

The  only  way  to  determine  that  the  continuence  of  the  first  stage  is 
not  endangering  the  life  of  the  fetus  is  to  listen  frequently  to  the  fetal 
heart  and  to  watch  carefully  for  changes  in  its  frequency  and  rh\-thm. 

While  a  long  continuation  of  the  first  stage  is  not  without  danger  to 
the  fetus,  its  risk  is  slight  as  compared  to  that  of  a  prolonged  second  stage 
with  which  most  of  the  fetal  dangers  are  associated.  Among  these  may 
be  mentioned: 

(a)  Asphyxia. — The  long,  dry  labor  with  perhaps  a  uterus  in  tonic 
contraction  exposes  the  fetus  to  risk  of  asph^-xia  from  compression  of 
placenta  and  cord  even  when  the  cord  is  in  normal  position.  ^Yhen  the 
cord  is  prolapsed,  as  so  often  happens  in  contraction  of  the  pelvic  inlet, 
this  danger  is  greatly  increased. 

(h)  Cerebral  Compression. — If  a  child  after  delivery  by  the  forceps 
shows  signs  of  cerebral  compression,  the  use  of  the  instrument  is  often 
blamed  for  the  result,  while  the  opposite  may  be  the  truth,  and  the 
delay  in  the  use  of  the  instrument,  allowing  the  fetal  head  to  remain 
subject  to  severe  pressure  for  too  long  a  period,  may  have  been  the  real 
cause  of  the  trouble.  One  not  infrequently  sees  the  result  of  cerebral 
compression  after  a  so-called  "normal  labor,"  /.  e.,  one  terminated  by 
nature,  but  where  the  pressure  was  too  prolonged.  It  must  be  recognized 
that  in  labor  in  a  contracted  pelvis  the  child  is  exposed  to  danger  of 
cerebral  compression  both  by  the  labor  itself,  if  it  is  difficult  and  markedly 
prolonged,  and  also  by  the  use  of  the  forceps,  if  this  operation  is  difficult. 

(c)  Sloughing  Areas  on  the  Fetal  Scalp. — The  prolonged  pressure  of 
the  fetal  head  against  some  bony  projection  in  a  contracted  pelvis  may 
show  its  result  after  birth  in  either  a  distinct  groove  in  the  child's  head 
where  the  bony  prominence  rested,  or  a  lowered  vitality  in  the  scalp 
at  that  point  with  subsequent  sloughing  which  may  both  lower  the 
general  vitality  of  the  child  and  serve  as  an  avenue  of  infection. 

AMiat  has  been  said  regarding  the  pressure  of  the  bony  projection  in 
the  pelvic  canal  on  the  fetal  head  may  also  apply  to  undue  and  unskilful 
pressure  of  the  forceps  blade  on  the  fetal  head  which  may  not  only  result 
in  sloughing  of  the  fetal  scalp  but  even  in  fracture  of  the  fetal  skull. 

(d)  Malpresentation  and  Malposition. — As  the  fetal  mortality  is 
increased  by  malpresentation  and  malposition,  and  as  these  are  both 
more  common  in  contracted  than  in  normal  pelves,  it  naturally  follows 
that  they  should  be  thought  of  when  explaining  the  fetal  mortality  in 
labor  associated  with  deformity  of  the  pelvis. 

Finally,  to  the  fetal  dangers  already  enumerated  should  be  added  the 
dangers  of 

(e)  Artificial  delivery,  and  when  one  considers  that  in  our  series  of 
1770  cases  with  deformed  pelvis  there  were  only  815,  or  46.4  per  cent., 
with  normal  labors,  it  is  e\ident  that  in  many  instances  the  fetal  danger 
from  the  forceps  and  version  must  be  included  among  those  associated 
with  labor  in  a  contracted  pelvis. 


CHAPTER  XXI. 

ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS  AND 
IN  PRESENTATION. 

ABNORMAL   LABOR    FROM    ANOMALIES    OF    THE    FETUS. 

Overgrowth  of  Fetus. — It  is  readily  understood  that  a  pelvis  of  a 
given  size  might  allow  an  easy  delivery  in  the  case  of  a  small  child,  while 
it  would  be  almost  impassable  to  an  abnormally  large  child.  It  is  seen 
then  that  for  a  normal  labor  much  depends  upon  the  size  of  the  child. 

Much  ignorance  exists  among  the  laity  regarding  the  actual  weight 
of  children  at  birth.  This  is  due  first  to  the  fact  that  there  seems  to  be 
a  widespread  tendency  to  exaggerate  the  weight  of  a  new  arrival  and  to 
take  especial  pride  if  the  child  is  unusually  large,  and  secondly,  to  the 
fact  that  it  is  the  custom  to  weigh  the  child  in  one  or  more  blankets,  and 
among  the  laity  the  weight  of  the  wrappings  is  not  accurately  deducted. 
Hence  it  is  not  unusual  for  the  proud  father  to  announce  that  he  has  a 
boy  weighing  all  the  way  from  12  to  15  pounds. 

At  the  Sloane  Hospital  the  net  weight  of  a  child  at  birth  is  accurately 
taken  and  recorded  in  the  delivery  room,  and  as  soon  as  the  baby  reaches 
the  nursery  it  is  weighed  again,  and  thus  the  actual  weight  is  attested 
by  two  observers. 

In  a  series  of  25,000  consecutive  deliveries  at  the  Sloane  Hospital,  the 
largest  normally  formed  child  weighed  twelve  pounds  three  ounces.  A 
few  monsters  weighed  more  than  this,  but  these  do  not  belong  in  a  series 
of  normally  formed  children. 

To  determine  the  average  weight  of  a  child  at  term  without  regard 
to  sex.  a  consecutive  series  of  5000  children  was  taken,  excluding  all 
whose  length  was  less  than  48  cm.  The  average  weight  was  7  pounds 
3  ounces.  In  this  series  of  5000  cases  there  were  2577  boys  with  an 
average  weight  of  7  pounds  4.1  ounces,  and  2423  girls  with  an  average 
weight  of  7  pounds  1.9  ounces.  Thus  the  average  actual  weight  was 
less  than  71  pounds,  and  the  boys  averaged  only  about  2  ounces  more 
than  the  girls. 

While  a  normal  pelvis  will  allow  the  easy  passage  of  a  75-pound  child, 
an  11-pound  child  may  give  marked  dystocia.  The  causes  of  unusual  size 
on  the  part  of  the  child  will  now  be  considered.  In  the  first  place  the 
overgrowth  may  be  due  to: 

Prolongation  of  Pregnancy. — It  has  already  been  stated  under  Duration 
of  Pregnancy  (see  page  157)  that  while  the  average  duration  of  pregnancy 
is  regarded  as  about  273  days  from  intercourse,  it  may  vary  from  231 
to  329  days,  and  this  variation  occurs  in  an^'mals  as  well  as  women. 

(697) 


698       ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS 

Moreover,  it  is  proNed  in  many  cases,  hy  the  al)normal  si/e  and  nnusnal 
development  of  the  eliild,  tliat  the  preti;nancy  has  been  abnormahy  pro- 
longed. In  some  instances  there  is  even  a  history  of  an  attempt  on  the 
part  of  nature  to  start  the  labor  at  the  usual  time,  but  for  some  reason 
the  symptoms  of  labor  ceased  (missed  labor)  and  only  recurred  weeks 
later. 

The  question  of  ])roloiigation  of  pregnancy  is  one  of  medicolegal  as 
well  as  obstetrical  importance,  and  concerns  the  legitimacy  of  children 
born  more  than  280  days  after  the  death  of  the  husband,  or  after  his 
last  possible  opportunity  for  intercourse. 

The  law  regarding  this  varies  in  different  countries.  In  France  and 
Austria  legitimacy  cannot  be  ciuestioned  unless  the  pregnancy  has 
exceeded  300  days.  In  England  and  America  no  exact  period  is  fixed 
and  each  case  is  decided  on  its  own  merits. 

It  is  admitted  then  by  practically  all  obstetricians  that  j^regnancy 
may  be  abnormally  prolonged  and  that  this  prolongation  may  give  rise 
to  such  overgrowth  of  the  fetus  as  to  cause  marked  dystocia.  The  dystocia 
resulting  from  overgrowth  of  the  child  concerns  chiefly  the  fetal  head 
and  shoulders. 

The  Head. — The  head  in  the  overde\'eloped  fetus  is  not  only  larger  but 
harder  and  less  moldable  and  for  both  of  these  reasons  the  mechanical 
problem  of  delivery  is  rendered  more  difficult. 

The  Shoulders. — The  shoulders,  moreover,  are  apt  to  be  broader  than 
normal  and  this  may  become  an  important  factor  in  the  dystocia. 

Oversize  of  One  or  Both  Parents. — An  important  question  in  taking  the 
history  of  every  obstetrical  case,  especially  if  the  woman  is  small,  concerns 
the  size  of  her  husband.  If  the  patient  herself  is  large  she  may  have  a 
large  pelvis,  but  at  any  rate  her  pelvis  should  be  carefully  measured,  as 
a  large  woman  often  has  a  large  child.  Of  greater  importance  is  the 
size  of  the  husband,  for  this  usually  means  a  large  child  and  the  jjossible 
dystocia  resulting  from  the  union  of  a  small  wife  with  a  large  husband  is 
readily  seen. 

Elderly  Primigravidse. — Sometimes  elderly  primigra\'idiTe  have  large  chil- 
dren, and  this  increased  size  of  the  fetus  c()U])led  with  the  tendency  to 
uterine  inertia  and  abnormal  resistance  in  the  soft  parts  often  means 
dystocia. 

Multiparity. — Unless  the  children  are  born  very  close  to  each  other 
there  is  a  tendency'  for  each  succeeding  child  \\\)  to  the  third  or  fourth 
at  least,  to  be  a  little  larger  than  the  ])receding,  so  that  a  woman, 
although  able  to  gi\-e  birth  to  her  first  or  second  child,  may  fail  in  her 
third  or  fourth. 

Treatment  of  Overgrowth  of  Fetus. — This  concerns  first  the  prolongation 
of  pregnancy.  Mistakes  are  so  frequent  in  calculating  the  exact  date  of 
a  confinement  that  the  obstetrician  must  be  cautious  in  deciding  that 
the  pregnancy  has  really  been  abnormally  prolonged.  Impregnation, 
instead  of  occurring  just  after  the  last  menstruation,  may  have  occurred 
just  prior  to  the  next,  which  did  not  appear,  and  this  would  account  for 
an  error  of  three  weeks  in  calculation.     As  a  rule,  however,  the  period 


Abnormal  lAbor  from  anomalies  of  the  fetus    609 

immediately  following  an  impregnation,  while  usually  greatly  diminished, 
is  not  entirely  checked,  and  this  scanty  or  irregular  menstruation  may 
assist  us  in  the  diagnosis. 

The  author's  rule  is,  never  to  allow  a  woman  to  go  more  than  two 
weeks  beyond  the  calculated  date  of  confinement,  without  frequent, 
careful  comparison  of  the  size  of  the  fetus  with  that  of  the  pelvic  canal; 
and  if  the  child  is  apparently  a  little  large  for  the  pelvic  canal,  to  consider 
that  an  indication  for  the  induction  of  labor. 

In  a  woman  whose  menstruation  has  been  previously  regular  and  who 
has  not  been  separated  from  her  husband,  three  weeks  may  be  considered 
the  limit  beyond  which  it  is  not  wise  to  allow  a  prolonged  pregnancy  to 
continue. 

In  all  cases  of  overgrowth  of  the  child  the  only  safe  management 
consists  in  frequent  palpation  of  the  child's  head  and  its  comparison 
with  the  pelvic  brim  and  the  consideration  of  a  justified  suspicion  of 
disproportion  as  an  indication  for  induction  of  labor. 

Some  women  have,  as  a  rule,  unusually  large  children  or  children  w^ith 
prematurely  ossified  heads,  and  hence  in  spite  of  normal  pelves  have 
more  or  less  dystocia.  This  may  be  impossible  to  determine  in  the  first 
pregnancy,  but  experience  gained  in  the  first  labor  is  often  of  the  greatest 
value  in  subsequent  pregnancies,  and  should  lead  to  the  most  careful 
observation  of  the  relative  size  of  child  and  pelvis  and  the  induction 
of  premature  labor  if  found  indicated  by  threatened  disproportion. 

If  the  disproportion  from  overgrowth  of  the  child  is  first  ascertained 
in  labor  and  through  nature's  inability  to  accomplish  the  delivery,  the 
obstetrician  is  often  face  to  face  with  a  serious  problem.  With  a  normal 
pelvis  one  is  loath  to  perform  either  Cesarean  section  or  pubiotomy, 
especially  in  the  first  labor;  and  if  forceps  or  version  fails,  it  may  be  too 
late  to  perform  one  of  the  major  operations  with  the  low  mortality  which 
it  is  recognized  should  belong  to  them. 

Malformations  of  the  Fetus. — Before  taking  up  the  individual  fetal 
malformations  it  will  be  found  desirable  to  note  carefully  the  following 
etymological  key,  arranged  by  Dr.  J.  Clifton  Edgar,  of  New  York, 
which  the  author  has  found  of  great  value  in  explaining  the  nomen- 
clature : 

Etymological  Key  .—Prefixes :  a-  or  an-,  "absence  of";  syn-  or  sym-, 
"fusion"  or  "blending  of  two  symmetrical  structures";  mono-,  "single" 
"undivided";  di-,  "two";  tri-,  "three";  anti-,  "opposed"  or  "oppo- 
site"; tetra-,  "four";  epi-,  "above";  hypo-,  "below";  ectro-,  "abor- 
tive", "defective,"  "rudimentary";  schisto-,  "cleft";  micro-,  "small"; 
hemi-,  "half."  Suffixes:  -pagus,  "united,"  "connected";  -schistos, 
"cleft."  Parts  of  body:  -cephalus,  "head";  -cormus,  "trunk";  -pygus, 
"breech";  -melus,  "limb"  ("extremity");  -thorns,  "chest";  -notos, 
"back";  -prosopos,  "face";  -crania,  "skull";  -rachis,  "spine";  -lecanus, 
" pelvis" ; -ischio,  "seat-bone";  -pus,  "foot,"  "leg";  -brachius,  "arm"; 
-ophthalmos,  -opos,  "eye";  -otos,  "ear". 

Only  the  more  common  fetal  malformations  and  those  likely  to  cause 
d^'stocia  will  be  considered  in  this  w^ork. 


roo 


ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS 


Hydrocephalus. — Tliis  is  one  of  the  commonest  forms  of  fetal  malforma- 
tion causing  dystocia.  At  the  Sloane  Hospital  for  Women,  in  20,000 
labors  there  were  14  cases  of  hydrocephalus. 

In  hydrocephalus  the  cerebral  A'entricles  are  distended  with  fluid 
and  the  whole  head  more  or -less  enlarged  (see  Fig.  411).  In  well-marked 
cases  the  cranial  bones  are  imperfectly  developed,  are  thin,  pliable  and 
separated  by  wide  sutures  and  large  fontanelles.  As  the  fluid  increases 
in  the  ventricles  the  brain  substance  becomes  thinned  and  crowded 
toward  the  cranium  initil  it  becomes  onh'  a  sac  containing  the  cerebral 
fluid. 


Fig.  411. — Frozen  section  of  hydrocephalic  head:  .4,  inner  wall  of  right  ventricle  and 
falx  cerebri;  B,  choroid  plexus;  C,  cerebellum;  D,  dilated  left  ventricle;  E,  optic  tract;  F, 
frontal  lobe. 


While  as  a  factor  in  causing  dystocia  only  antepartum  hydrocephalus 
is  considered,  still  it  may  be  mentioned  that  one  of  the  disappointments 
of  the  obstetrician  is  to  meet  with  the  gradual  development  of  a  hydro- 
cephalus in  a  child  which  at  birth  showed  no  evidence  of  the  condition 
save  perhaps  the  fact  that  it  was  not  strong  and  well  developed.  In 
the  author's  experience  this  has  occurred  most  frequently  in  premature 
babies  and  has  appeared  within  the  first  two  or  three  weeks  after  birth. 

Diagnosis. — Unless  the  fetal  head  is  very  much  enlarged  so  that 
fluctuation  and  perhaps  a  peculiar  crackling  sensation  of  the  fetal  skull 
can  be  detected  on  palpation  of  the  woman's  abdomen,  the  diagnosis  is 


ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS      701 

usually  not  made  until  after  several  hours  of  strong,  second-stage  pains, 
with  a  normal  pelvis  and  vertex  presentation,  it  is  found  that  the  present- 
ing part  does  not  advance.  If  the  presentation  is  a  breech,  the  diagnosis 
is  usually  not  made  until  it  is  found  that  there  is  an  obstacle  to  the  extrac- 
tion of  the  after-coming  head.  In  both  these  instances  careful  palpation, 
with  the  hand  inserted  into  the  vagina  if  necessary,  will  usually  detect 
the  large  head,  the  thin  pliable  bones,  the  large  fontanelles  and  broad 
sutures.    Certain  possible  errors  of  diagnosis  are  worthy  of  mention. 

In  the  first  place  the  hydrocephalus  may  be  in  its  early  stages,  the 
ventricles  may  be  full  and  somewhat  distended,  but  the  fetal  head  instead 
of  being  markedly  enlarged,  with  thin  bones,  broad  sutures  and  large 
fontanelles,  may  be  but  little  enlarged,  yet  on  account  of  the  distended 
tense  ventricles,  may  be  almost  incompressible.  Such  a  fetal  head  is 
easily  confused  with  an  ordinary  large  head  or  a  prematurely  ossified 
head. 

Another  condition  may  lead  one  into  error:  The  head  may  lie  high  in 
the  pelvis  and  a  parietal  bone  present  in  such  a  way  that  no  sutures  or 
fontanelles  can  be  felt  without  inserting  the  hand  into  the  vagina. 

On  account  of  the  difficulty  in  many  cases  in  detecting  a  slight  lumbar 
obstruction  to  the  entrance  of  the  head  into  the  pelvic  brim,  the  lack 
of  engagement,  when  no  sutures  or  fontanelles  are  palpable,  may  easily 
be  assigned  to  a  lumbar  obstruction  requiring  Cesarean  section.  It 
is  not  well  to  make  a  vaginal  examination  with  the  whole  hand  upon 
cases  to  be  subjected  to  Cesarean  section  on  account  of  the  added  risk 
of  infection,  hence  the  one  criterion  of  hydrocephalus  which  would 
determine  the  condition  is  omitted.  The  author  once  fell  into  this  error 
and  was  chagrined  to  deliver  by  Cesarean  section  a  hydrocephalic  child. 

In  very  rare  cases  the  sutures  and  fontanelles  are  so  widened  and 
enlarged  that  under  the  pressure  of  very  severe  uterine  contractions  a 
rupture  of  one  of  the  sutures  or  fontanelles  may  occur  with  an  escape 
of  the  intra-cranial  fluid  and  a  collapse  of  the  fetal  head,  followed  by  a 
spontaneous  delivery.  This  is  so  extremely  rare  during  any  duration 
of  the  second  stage,  which  is  safe  for  the  mother,  that  it  is  never  to  be 
expected. 

Prognosis. — The  maternal  prognosis  of  fetal  hydrocephalus  depends 
chiefly  upon  the  care  received  by  the  mother.  An  early  recognition  of 
the  condition  by  the  obstetrician  and  an  early  reduction  in  the  size  of  the 
fetal  head  usually  saves  the  mother  from  danger.  On  the  other  hand, 
the  neglect  of  a  woman  in  labor  with  a  hydrocephalic  fetus  exposes  her 
to  the  risk  of  ruptured  uterus,  and  repeated  trials  of  delivery  by  forceps, 
with  the  tendency  of  the  blades  to  slip,  exposes  her  to  the  risks  of  exten- 
sive lacerations  and  subsequent  infection.  The  fetal  prognosis  is  abso- 
lutely bad,  and  fortunate  it  is  for  all  concerned  if  fetal  life  ceases  at  birth 
rather  than  continues  to  become  a  hopeless  imbecile. 

Treatment. — It  may  be  said  that  the  most  important  factor  in  the 
treatment  of  hydrocephalus  is  the  diagnosis.  As  soon  as  the  diagnosis 
is  positively  made,  the  life  of  the  child  may  be  disregarded,  for  even  if 
it  is  born  alive,  its  life  is  usually  very  short,  and  it  is  a  comfort  neither 


702       ABXORMAL   LABOR  FROM  AXOMALIES  OF  THE  FETUS 


to  its  parents  nor  to  tlu-ir  friends.  For  these  reasons  the  mother's  welfare 
should  alone  he  considered.  This  usually  demands  reduction  in  the  size 
of  the  fetal  head.  An  exception  to  this  rule  may  ohtain  in  the  instance 
where,  for  the  descent  of  jjroperty  or  the  fulfillment  of  other  conditions, 

it  is  very  imj)ortant  that  a  livinoj  child 
should  be  born,  even  if  it  lives  only 
for  a  few  moments. 

The  ordinary  active  treatment,  a.s 
has  been  indicated  consists  in  the 
reduction  in  size  of  the  fetal  head. 
This  is  accomplished  by  perforation 
through  one  of  the  sutures  or  fonta- 
nelles.  This  perforation  may  be  done 
both  in  breech  and  in  vertex  presen- 
tations with  a  strong  pair  of  sharp- 
]jointed  scisst)rs.  However,  in  vertex 
cases  especially,  it  is  best  done  by 
such  an  instrument  as  the  perfor- 
ator of  the  Tarnier  basiotribe,  to 
which  the  crushing  blades  may  be 
a])])lied,  and  the  delivery  facilitated 
by  craniotomy  if  necessary.  It  is 
important  for  the  moral  effect  upon 
the  parents  and  friends  that  the 
child  whose  head  has  been  perforated 
should  not  be  born  alive,  hence  it  is 
desirable  that  the  perforator  should 
be  passed  to  the  medulla  and  moved 
about  freely.  As  a  rule  there  is 
little  difficulty  in  reaching  the  head 
sufficiently  to  perforate,  but  if  in  a 
breech  presentation  this  is  found  to 
be  extremely  difficult,  the  method 
of  puncturing  the  spinal  canal  and 
passing  a  catheter  along  it  into  the 
cranial  cavity,  as  recommended  by 
Van  Huevel,  may  be  followed. 

Anencephalous  Monster. — In  contra- 
distinction to  hydrocephalus,  with 
its  large  fetal  head,  there  may  occur  a  monster  lacking  a  large  part 
of  the  brain  sulxstance  and  skull  and  presenting  a  small  head  which  is 
mostly  face.  It  is  seen  by  a  glance  at  Fig.  412  that  the  head  in  this 
condition  is  not  likely  to  cause  dystocia,  but  often  these  cases  have  large 
trunks  and  the  delivery  of  the  shoulders  is  not  infrequently  difficult. 

Diagnosis. — The  \aginal  feel  of  an  anencephalous  monster  with  a 
cephalic  presentation  is  often  at  first  confusing.  However,  the  pro- 
trusion of  the  eye-balls  and  perhaps  of  the  tongue,  when  the  presentation 
is  a  face,  which  it  commonly  is,  and  the  absence  of  the  cranial  xault  and 


Fig.  412. — -Anencephalous  monster. 


Xiphopagus.     (Hirst  and  Piersol.) 


ABXORMAL  LABOR  FROM  AXOMALIES  OF   THE  FETUS      703 

the  feeling  of  the  sella  turcica  Avhen  the  presentation  is  a  vertex,  will 
often  enable  the  correct  diagnosis  to  be  made. 

Prognosis. — ^The  maternal  prognosis  usually  differs  but  little  from^  that 
of  a  normal  labor  if  the  patient  is  in  the  hands  of  a  skilled  obstetrician, 
as  the  dystocia  is  usually  not  marked. 

The  fetal  prognosis  is  fortunately  absolutely  bad  and  the  child,  if  born 
alive,  usually  dies  within  a  few  moments.  Twice  in  the  author's  experience 
one  of  these  monsters  has  lived  for  about  a  day. 

Treatment— If  artificial  delivery  of  an  anencephalic  monster  is  indi- 
cated, a  version  with  breech  extraction  is  the  best  procedure,  provided 


Fig.  413. — Pygopagus. 


version  is  not  contra-mdicated  by  a  tonic  condition  of  the  uterus.  The 
after-coming  head  naturally  presents  little  difficulty. 

If  marked  dystocia  arises  from  the  breadth  of  the  shoulders,  it  can  be 
overcome  by  section  of  one  of  the  clavicles.  As  a  rule,  however,  the 
delivery  of  an  anencephalic  monster  either  occurs  spontaneously  or  can 
be  terminated  by  a  version  and  breech  extraction. 

Double  Monsters. — ^^Yhile  great  varieties  of  duplication  are  found  in 
different  monsters,  for  practical  purposes  three  classes  of  double  monsters 
may  be  distinguished. 


704       ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS 

1.  Monsters  with  separate  bodies  joined  loosely  by  the  front  or  back 

of  trunk,  xiphopagus  (see  Plate  XI)  or  pygopagus  (see  Fig.  413). 

The  Siamese  twins  were  an  example  of  xiphopagus,  and  the  Hungarian 
sisters  of  pygopagus. 

2,  Monsters  with  duplication  of  upper  part  of  bod^• — dicephahis  (see 
Plate  XII). 


Fig.  414. — Tetrapus. 

3.  Monsters  with  duplication  of  lower  part  of  bodv — tetrapus  (see 
Fig.  414). 

Diagnosis. — Although  multiple  pregnancy  is  often  suspected,,  the  diag- 
nosis of  a  double  monster  is  usually  not  made  until  the  hand  is  intro- 
duced to  ascertain  the  cause  of  the  protracted  labor. 


PLATE   XII 


Dieephalie  Monster. 

Photograph  presented  to  the  author  by  Drs.  Hupp  and  Quimby. 


ABNORMAL  LABOR  FROM  ANOMALIES  OF   THE  FETUS      705 

Mechanism. — It  can  hardly  be  said  there  is  a  regular  definite  mechanism 
in  the  delivery  of  double  monsters,  but  the  principle  which  seems  to 
guide  nature  in  accomplishing  the  desired  result  is  worthy  of  great 
admiration.  By  advancing  first  a  part  of  one  duplicate  and  then  a  part 
of  the  other,  by  the  molding  of  each,  and  the  fitting  of  one  into  the 
other,  spontaneous  delivery  is  often  accomplished  in  a  wonderful  way. 

Fortunately  premature  labor  is  common  in  these  conditions,  hence 
each  half  of  the  double  monster  is  apt  to  be  smaller  than  in  a  full-term, 
single  pregnancy.  Nature  can  often  be  assisted  in  her  task  of  delivery, 
by  pushing  up  one  part  and  allowing  the  other  to  advance.  In  double- 
headed  monsters  this  method  is  often  of  value.  It  occasionally  happens, 
however,  that  the  advance  of  one  head  is  blocked  by  the  impaction  of 
the  other,  and  in  such  a  case,  craniotomy  or  amputation  of  the  first  head 
is  the  procedure  of  choice.  The  monster  can  then  usually  be  delivered 
by  forceps  or  version. 

Dystocia  from  Enlargement  of  the  Fetal  Body. — Occasionally  the 
fetal  abdomen  is  found  of  such  a  size  that  natural  delivery  is  impos- 
sible. This  abdominal  enlargement  is  usually  the  result  of  one  or  more 
of  the  following  conditions:  Ascites;  tumors  of  the  kidneys  or  liver;  a 
markedly  distended  bladder. 

Occasionally,  as  a  result  of  obstruction  of  the  circulation  through  the 
fetal  liver,  the  abdomen  becomes  immensely  distended  with  ascitic  fluid, 
making  delivery  impossible  without  first  tapping  and  drawing  off  the 
fluid.  At  times  associated  with  this  condition,  or  independent  of  it, 
there  occurs  an  obstruction  of  the  superficial  lymphatics  of  the  body 
causing  a  marked  edema  of  the  subcutaneous  tissue  of  the  fetus  with 
great  enlargement  of  its  trunk. 

One  of  the  most  common  causes  of  abdominal  enlargement  causing 
dystocia  of  fetal  origin  is  a  congenital  cyst  of  one  or  both  kidneys.  These 
cysts  often  grow  rapidly  and  to  an  immense  size,  often  making  the 
abdomen  the  largest  part  of  the  fetus  and  naturally  causing  marked 
dystocia. 

Tumors  of  the  liver  and  other  viscera  are  occasionally  found  as  the 
cause  of  the  abdominal  enlargement  causing  dystocia  of  fetal  origin. 

In  the  case  of  atresia  of  the  lower  urinary  tract,  the  fetal  bladder  may 
become  so  distended  as  to  fill  and  distend  the  whole  abdomen. 

Diagnosis. — As  a  rule  the  diagnosis  of  dystocia  arising  from  conditions 
of  the  fetal  abdomen  or  trunk  is  not  made  until  after  the  birth  of  the 
head.  Delay  then  naturally  leads  to  investigation,  even  the  introduction 
of  the  hand  into  the  uterus,  and  the  true  cause  of  the  dystocia  is  found. 
In  the  treatment  of  the  condition  the  life  of  the  fetus  receives  but  little 
consideration,  as  the  condition  is  usually  incompatible  with  the  future 
health  of  the  fetus,  and  the  usual  indication  is  to  open  the  abdomen  of 
the  child  and  reduce  its  bulk  so  as  to  aflow  delivery  through  the  natural 
passages. 

External  Tumors  of  the  Fetus. — Aside  from  tumors  of  the  abdomen 
mentioned  above,  certain  external  tumors  of  the  fetus  occasionally 
occur  and  give  rise  to  dystocia,  or  at  any  rate  to  confusion  in  diagnosis. 
45 


70G       ABNORMAL  LABOR  FROM  ANOMALIES  OF   THE  FETUS 

Exani])les  of    these  are   a  myxoma,   or   a   lym])liaii^ioma   of  the  neck 
preventing  flexion;  a  teratoma  of  the  sacrum,  an  encephalocele,  or  an 


Fig.  415. — Case  of  hydrencephaloccle.     (Microcophalus.) 

hydrencephalocele    (see   Fig.    415   and    Plate    XIII)   or  a   meningocele 
(see  Fig.  416). 

In  many  of  these  fetal  tumors,  if  dystocia  is  present,  it  is  often  over- 
come by  following  the  principle  of  nature  in  the  delivery  of  double 
monsters,  /.  c,  the  propulsion  of  first  one  part  and  then  another.    Bear- 


FiG.  41G. — Spina  l)ifitla.     Meningocele. 


ing  this  in  mind,  the  obstetrician  may  push  U])  the  obstructing  object, 
and  thus  facilitate  deliverv. 


X 

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o 


DYSTOCIA  ARISIXG  FROM  PRESEXTATIOXS  OF   THE  FETUS     707 

Cases  of  encephalocele  rarely  give  rise  to  dystocia,  as  they  are  situated 
chiefly  in  the  occipital  or  frontal  regions,  usually  the  former,  and  are 
expelled  either  before  or  after  the  head.  Moreover,  the  cranial  bones 
about  the  opening  are  usually  softer  and  more  yielding  than  normal. 
The  case,  of  which  Figs.  415  and  Plate  XIII  are  drawings,  occurred  in 
the  author's  service  at  the  Sloane  Hospital  and  was  delivered  easily. 

The  case  of  meningocele,  of  which  Fig.  416  is  a  photograph  of  the 
specimen,  was  seen  by  the  author  in  consultation  with  Dr.  Brooks,  of 
Greenwich,  Conn.,  and  presented  an  interesting  complication.  The 
child  was  normally  delivered,  but  during  the  birth  the  large  meningeal 
sac  was  ruptured  and  bled  quite  profusely.  The  author  excised  the  sac 
and  approximated  the  muscles  over  the  lumbar  opening.  The  child 
made  a  good  recovery  and  is  now  fourteen  years  old  and  in  good  health 
save  for  a  slight  lack  of  control  over  bladder  and  bowel. 


Fig.  417. — Transverse  or  shoulder  presentation.     (Bumm.) 


DYSTOCIA  ARISING  FROM  ABNORMAL  PRESENTATIONS  OF 

THE  FETUS. 

Transverse  Presentations. — In  these  presentations  the  long  axis  of 
the  fetus,  instead  of  corresponding  with  that  of  the  mother,  crosses  it  at 
an  angle  which  approaches  a  right  angle  (see  Fig.  417).  Under  the 
term  transverse  presentation  are  included  presentations  of  any  portion 
of  the  fetal  trunk,  but  as  all  transverse  presentations  usually  change  to 
a  shoulder  presentation  as  labor  advances,  a  transverse  presentation  is 
often  called  a  shoulder  -preseniation. 

Varieties. — Transverse  presentations  are  classified  according  to  the 
positions  of  the  fetal  back  and  head.    Thus  the  fetal  back  may  be  anterior 


708        ABNORMAL  LABOR  FROM  ANOMALIES  OF   THE  FETUS 

or  posterior  and  the  fetal  head  may  lie  to  the  left  or  to  the  right,  hence 
four  positions  of  a  transverse  presentation  are  possible: 
Left  dorso-anterior 


Left  dorsoposterior 


with  head  to  the  left. 


Right  dorso-antenor  ]      -,1,1,      i  j.    ^u      •  u^. 
T-> .  1  ,  1  ^    .       >  with  head  to  the  right. 

Right  dorsoposterior  j 

Frequency. — Li  a  series  of  20,000  consecutive  deliveries  at  the  Sloane 
Hospital  there  were  181  cases  of  transverse  presentation.  Li  other  words, 
transverse  presentations  occurred  once  in  every  111  cases.  As  to  the 
frequency  of  the  different  positions,  dorso-anterior  positions  were  much 
more  frequent  than  dorsoposterior,  and  the  fetal  head  was  found  more 
frequently  on  the  right  side  than  on  the  left.  Thus,  of  the  181  cases  of 
this  series,  123  were  dorso-anterior  while  only  50  were  dorsoposterior. 
In  102  the  head  was  on  the  right  and  in  71  on  the  left  side  of  the  mother. 
In  8  cases  the  position  of  the  child  was  not  specified  in  the  history. 

Etiology. — The  etiological  factors  leading  to  a  transverse  presentation 
may  usually  be  grouped  under  three  heads: 

1.  Abnormal  Mohility  of  Fetus. — ^This  is  seen  in  multigravidje  with 
lax  uterine  and  abdominal  walls.  In  the  author's  series  of  181  cases, 
there  were  144  multigravidse  and  only  37  primigravidse. 

Ilydramnios  with  excessive  mobility  of  the  fetus  favors  transverse 
presentations. 

Prematurity  with  a  small,  freely  movable  fetus  is  often  associated  with 
a  transverse  presentation.  In  the  above  series  of  181  cases  87  cases  were 
premature. 

2.  Disproportion  between  Presenting  Part  and  Parturient  Canal,  or 
Conditions  Preventing  Cephalic  or  Pelvic  Engagement. — This  is  especially 
seen  in  cases  of  deformed  pelvis,  monstrosities,  placenta  previa,  etc. 
In  the  author's  series  of  181  transverse  presentations  there  were  48  cases 
of  deformed  pelvis. 

3.  Abnormalities  in  the  Position  and  Shape  of  the  Uterus. — Examples 
of  these  are  seen  in  cases  of  pendulous  abdomen,  uterus  bicornis,  and  in 
uteri  deformed  by  fibromyomata. 

Diagnosis. — The  diagnosis  can  often  be  made  by  inspection  of  the 
woman's  abdomen  and  can  easily  be  determined  by  abdominal  and 
vaginal  palpation. 

On  inspection  the  longest  diameter  of  the  uterus  is  seen  to  be  the 
transverse. 

On  abdominal  palpation  the  fetal  head  is  found  in  one  flank  and  the 
breech  in  the  other. 

On  vaginal  examination  the  first  thing  noticed  is  usually  the  absence 
of  the  head,  and  it  may  be  possible  to  detect  the  spine  of  the  scapula, 
or  the  clavicle  and  in  some  cases  the  ribs. 

If  the  membranes  are  ruptured  and  the  arm  prolapsed  the  diagnosis 
is  usually  easy,  although  the  differential  points  between  the  hand  and 
foot,  mentioned  on  page  297   may  be  of  value. 

Prognosis. — As  the  termination  of  a  transverse  presentation  by  natural 
labor  is  extremely  rare,  the  prognosis  for  both  mother  and  child  depends 


DYSTOCIA  ARISING  FROM  PRESENTATIONS  OF  THE  FETUS 


109 


largely  upon  the  treatment  adopted.  If  the  diagnosis  is  made  and  the 
position  corrected  early  the  prognosis  is  good.  The  longer  the  case 
goes  untreated,  the  worse  the  prognosis. 

Mechanism.— As  a  rule  no  mechanism  of  labor  in  a  transverse  presen- 
tation is  to  be  expected. 

As  contractions  of  the  uterus  occur,  the  usual  result,  in  a  case  untreated, 
is  an  impaction  of  the  shoulder,  with  a  marked  dilatation  of  the  lower 
uterine  segment;  a  retraction  of  the  upper  uterine  segment;  death  of 
the  fetus  from  long  pressure;  perhaps  death  of  the  ipother  from  rupture 
of  the  uterus,  or  exhaustion  and  sepsis.  There  are  two  possible  ways  in 
which  nature  in  rare  cases  succeed  in  delivering  the  child  unaided: 
(a)  Spontaneous  version. 
(6)  Spontaneous  evolution. 

Spontaneous  Version. — Occasionally  under  the  influence  of  the  first 
few  pains  of  labor,  a  transverse  presentation,  which  has  persisted  for  a 


Fig.  418. — Spontaneous  evolution.    (Bumm.) 

considerable  time  during  pregnancy,  will  be  converted  into  a  longitudinal 
presentation.  This  may  be  brought  about  by  the  uterine  contractions 
themselves  and  is  more  apt  to  occur  in  multigravidee  with  lax  uterine  and 
abdominal  walls,  with  plenty  of  room  for  the  child  to  move,  with  cervix 
undilated,  membranes  intact,  shoulder  not  engaged,  uterine  contractions 
strong  and  child  alive.    This  process  is  called  spontaneous  version. 

Syontaneons  Evolution. — Under  certain  conditions,  as  in  premature 
labors  \\dth  a  fetus  small  or  macerated,  with  a  pelvis  of  large  size  and 
uterine  contractions  strong,  nature  sometimes  succeeds  in  crowding 
one  part  of  the  fetus  past  the  other  and  delivering  the  child  (see  Fig. 
418).  Thus  the  breech  may  be  crowded  past  the  shoulder  and  delivered 
■first,  the  rest  of  the  body  following  as  in  a  breech  presentation;  or  still 
more  rarely,  with  the  shoulder  leading,  the  fetus  may  be  folded  on  itself 
and  expelled  as  one  mass  (see  Fig.  419).  These  processes,  called  spon- 
taneous evolution,  are  never  to  be  expected  with  a  full-term  living  child, 
in  fact  spontaneous  evolution  almost  never  occurs  save  with  a  small, 
dead  child,  a  large  pelvis,  and  strong  uterine  contractions. 


710       ABNORMAL  LABOR  FROM  ANOMALIES  OF   THE  FETUS 

Treatment. — The  treatment  of  a  transverse  presentation  ma}-  be 
summed  up  in  one  word — version. 

If  the  diagnosis  is  made  })efore  labor,  external  version  should  be  tried. 
As  a  rule  external  eei)halic  version  should  be  attempted,  but  if  the 
obstetrician  does  not  succeed  in  causing  the  head  to  present,  and  the 
breech  is  much  nearer  the  pelvic  inlet,  he  should  be  satisfied  with  an 


Fig.  419. — Spontaneous  evolution.     (Bunim.) 


external  pelvic  version.  If  the  case  is  first  seen  after  the  membranes  have 
ruptured  and  the  shoulder  has  presented,  the  treatment  indicated  is  an 
internal  podalic  version,  unless  version  is  contra-indicated  by  a  tonic  con- 
dition of  the  uterus.  Attention  has  already  been  directed  to  the  danger 
of  version  in  a  tonic  uterus  (see  page  623),  and  this  danger  shonld  be 
emphasized  here,  as  in  the  neglected  transverse  presentations  with 
shoulder  impacted,  the  lower  uterine  segment  is  usually  thinned  and  any 
attempt  at  version  is  likely  to  be  followed  by  a  rupture  of  the  uterus. 


DYSTOCIA  ARISING  FROM  PRESENTATIONS  OF  THE  FETUS     711 

While  version  is  the  treatment  indicated,  if  the  case  is  seen  soon  after  the 
rupture  of  the  membranes  and  before  the  uterus  has  become  tonic,  if 
the  case  has  been  neglected,  the  shoulder  has  become  impacted  and  the 
child  is  dead  or  dying,  decapitation  is  the  operation  of  choice.  Cesarean 
section  is  usually  contra-indicated  in  neglected  transverse  presentations, 
both  on  account  of  the  danger  of  infection  and  also  for  the  reason  that  the 
vitality  of  the  child  has,  as  a  rule,  already  been  reduced.  It  is  often 
necessary  to  completely  anesthetize  the  woman  before  determining  that 
the  uterus  is  too  tonic  to  admit  of  a  safe  version. 

Abnormalities  of  Breech  Presentation. — Breech  Extraction. — A  breech 
presentation  may  present  abnormalities  of  mechanism  leading  to  marked 
dystocia.  These  abnormalities  arise  chiefly  from  the  faulty  position  of 
the  legs  or  the  arms. 

Breech  Presentation  with  Extended  Legs  or  a  "Frank  Breech." — This 
condition  has  already  been  described  in  the  chapter  on  Mechanism  of 
Labor  (page  247)  (see  Fig.  420) .  Many  cases  of  breech  presentation  with 
extended  legs,  if  the  fetus  is  small  and  the  pelvis  large,  will  deliver  them- 
selves spontaneousl}'.  On  the  other  hand,  if  the  fetus  is  large  the  exten- 
sion of  the  legs  may  produce  so  great  a  wedge  with  the  base  formed  by 
the  fetal  trunk  and  legs  that  labor  is  unduly  prolonged  and  perhaps 
obstructed.  In  all  such  cases  the  indication  is  to  break  up  the  wedge  by 
pulling  down  one  foot.  As  the  longer  this  is  delayed  after  the  rupture  of 
the  membranes,  the  harder  the  procedure  becomes,  it  naturally  follows 
that  the  question  as  to  whether  in  a  frank  breech  presentation  one  foot 
should  be  brought  down  early  in  the  second  stage  is  an  important  one. 
The  author's  rule  is  to  bring  down  a  foot  in  every  case  of  frank  breech 
presentation  unless  the  patient  is  a  multigravida  with  relatively  small 
fetus  and  plenty  of  room,  or  a  primigravida  with  a  small  fetus. 

Technic. — One  of  the  first  essentials  in  the  technic  of  bringing  down 
a  foot  in  a  frank  breech  is  sufficient  dilatation  of  the  cervix  to  allow 
of  the  passage  of  the  obstetrician's  hand.  Hence,  if  the  cervix  is  not 
already  dilated,  the  dilatation  should  be  increased  manually  until  the 
hand  easily  passes.  The  hand  selected  should  be  that  whose  palm  corre- 
sponds to  the  abdomen  of  the  fetus  as  in  a  podalic  version.  Passing 
the  hand  along  the  anterior  thigh  of  the  fetus  until  the  popliteal  space  is 
reached,  pressure  is  made  here  forcing  the  knee  away  from  the  midline 
of  the  fetal  abdomen  and  toward  the  fetal  back.  This  usually  tends  to 
flex  the  leg  so  that  the  obstetrician's  forefinger,  or  fore-  and  middle  fingers 
may  easily  be  slipped  over  the  knee  and  down  the  leg  to  the  foot.  The 
foot  is  then  brought  down  into  the  vagina,  leaving  the  other  leg  extended 
to  serve  with  the  fetal  trunk  as  a  good  dilator  of  the  parturient  canal. 
With  a  foot  and  leg  of  the  fetus  drawn  down  into  the  vagina  the  obstetri- 
cian has  in  them  the  tractor  needed  in  case  nature  is  unable  to  continue 
the  expulsion  of  the  fetus  unaided.  It  must  be  borne  in  mind,  however, 
that  in  every  breech  delivery,  whether  it  be  that  of  a  normal  complete 
breech,  or  the  extraction  after  a  podalic  version,  or  the  extraction  of  a 
frank  breech,  it  is  desirable  to  have  as  much  of  the  delivery  as  possible 
brought  about  by  uterine  contractions  aided  by  the  downward  pressure  of 


712       ABNORMAL  LABOR  FROM   ANOMALIES  OF  THE  FETUS 

an  assistant  or  nurse  upon  the  fundus.  In  other  words,  progress  if  possible 
should  come  through  downward  pressure  from  above  rather  than  through 
downward  traction  from  below.  The  pressure  of  an  assistant  or  nurse 
upon  the  fundus  tends  both  to  maintain  flexion  of  the  fetal  head  and 
to  prevent  extension  of  the  arms  by  the  side  of  the  head.  In  most  cases 
of  frank  breech  presentation  with  the  patient  under  anesthesia  it  is  pos- 
sible to  gently  introduce  the  hand  into  the  uterus,  seize  a  foot  as  described 
above,  and  draw  it  down  into  the  vagina,  thus  breaking  up  the  wedge. 


Fig.  420. — Frank  breech  presentation. 

Some  authors  speak  of  the  necessity  of  using  the  blunt  hook  or  a  fillet 
in  the  fetal  groin  as  a  tractor  for  the  imjjacted  breech.  Such  has  never 
been  the  author's  experience,  as  he  has  always  been  fortunate  enough  to 
be  able  to  deliver  the  breech  by  bringing  down  a  foot  and  using  that  as  a 
tractor  or  else  by  insertion  of  his  fingers  in  one  or  both  fetal  groins  and 
exerting  traction  there,  aided  by  the  pressure  of  an  assistant  upon  the 
uterine  fundus.  The  author  would  be  very  loath  to  use  a  blunt  hook 
for  this  purpose  on  account  of  the  danger  to  the  soft  parts  of  the  fetus 
and  perhaps  fracture.    The  danger  of  the  slipping  of  the  blunt  hook  and 


DYSTOCIA  ARISING  FROM  PRESENTATIONS  OF  THE  FETUS     713 


injuring  the  soft  parts  of  the  mother  should  be  borne  in  mind  here  as 
well  as  in  its  use  upon  a  dead  child  in  the  course  of  a  craniotomy.  The 
fillet,  although  less  dangerous  than  the  blunt  hook,  can  do  considerable 
damage  to  the  soft  parts.  The  author,  in  his  more  than  twenty-five  years 
of  obstetric  experience,  has  never  found  it  necessary  to  apply  the  forceps 
to  an  impacted  breech.  He  can  imagine  a  condition  in  which  this  would 
be  justifiable,  but  he  would  prefer  under  these  circumstances  application 
of  the  blades  over  the  trochanters  rather  than  the  oblique  application, 
with  one  blade  over  the  sacrum  and  one  over  the  thigh,  as  recommended 
by  some. 

Abnormalities  from  Position  of  the  Arms. — The  criterion  of  a  successful 
breech  delivery  often  depends  upon  the  position  of  the  fetal  arms.  In  a 
complete  breech  presentation  with  normal  mechanism,  as  already  described 
(page  297),  the  thighs  and  legs  are  flexed,  bringing  the  feet  near  the 


Fig.  421. — Breech  delivery  with  extended  arms.    Reaching  for  bend  of  elbow. 

buttocks  and  near  the  cervix;  the  arms  are  flexed  and  folded  on  the  chest 
so  that  soon  after  the  birth  of  the  navel  the  elbows  come  within  easy 
reach  of  the  obstetrician  so  that  the  forearms  can  be  extended  and 
delivered  with  little  difficulty. 

Two  abnormalities  in  the  position  of  the  arms  may  greatly  complicate 
a  breech  delivery : 

1.  One  or  both  arms  may  be  extended  by  the  side  of  the  fetal  head 
(Fig.  421). 

2.  One  arm  may  lie  behind  the  fetal  neck — the  nuchal  hitch,  as  it  is 
called  (Fig.  423). 

Etiology. — The  most  common  cause  of  extension  of  the  fetal  arms  is 
traction  on  one  or  both  legs  of  the  fetus  from  below,  as  in  a  podalic  ver- 
sion or  in  a  hastened  breech  extraction.  This  complication  is  especially 
apt  to  occur  if  constant  pressure  is  not  exerted  on  the  uterine  fundus 
and  flexion  of  the  fetal  head  maintained.     This  pressure  from  above 


714 


ABXORMAL   LABOR   FROM   AXOMALIES  OF  THE   FETUS 


tends  to  kvv\)  tho  iiorinal  attitude  of  the  fetus  as  far  as  head  and  arms  are- 
coneerned.     The  most  common  cause  of  the  nuchal  hitch  is  a  rotation 
of  the  fetal  trunk  c()nil)ined  with  traction  from  below. 

Tri'dfiiicttf. — When  considering  the  treatment  of  a  hreech  i)resentation 
with  extende(^l  arms  attention  should  lie  directed  to  the  yrophylaxis 
and  the  importance  in  every  breech  delivery  of  having  an  assistant  or 
nurse  exert  firm  downward  pressure  upon  .the  fundus  uteri  while  the 
obstetrician  is  exerting  traction  from  below.  The  object  of  this  fundal 
pressure  is  to  prevent  the  complication  of  extended  arms. 

Active  Treatment. — If  the  fetus  is  of  full  size  there  is  not  room  in  an 
average  pelvis  for  the  head  to  pass  with  the  arms  extended  by  its  side, 
and  unless  the  complication  can  be  relieved  in  about  five  minutes  the 
fetal  life  is  usually  lost.  As  the  parts  are  more  yielding  posteriorly  than 
anteriorly,  it  is  the  posterior  arm  which  is  first  sought  and  brought  down 


Fig.  422. — Breech  delivery  with  extended  arms.     With  finger  in  bend  of  elbow,  making 
arm  sweep  across  face  and  down  along  chest. 

(Fig.  421).  Rotating  the  fetal  body  so  that  the  posterior  shoulder  lies 
in  the  hollow  of  the  sacrum,  the  obstetrician's  hand  is  passed  along  the 
back  of  the  fetus,  over  the  shoulder  and  down  the  arm  to  the  elbow. 
Traction  should  not  be  exerted  until  the  elbow  is  reached,  as  otherwise 
the  humerus  is  easily  fractured.  With  a  finger  or  fingers  in  the  bend  of 
the  fetal  elbow  the  arm,  as  a  rule,  is  easily  made  to  sweep  across  the 
face  and  down  across  the  chest  (Fig.  422).  With  one  arm  delivered  the 
fetal  body  is  rotated  so  as  to  brmg  the  other  arm  posterior.  The  obstetri- 
cian now  changes  the  hand  holding  the  feet  of  the  fetus  and  with  his  free 
hand  passed  up  along  the  fetal  back  and  over  the  shoulder  to  the  bend 
of  the  elbow  he  brings  down  the  other  arm. 

Breech  Delivery  Complicated  by  a  Nuchal  Hitch. — The  object  desired 
in  this  condition  is  first  to  get  the  arm  which  lies  behind  the  fetal  neck 
to  slide  forward  to  the  side  of  the  head,  when  the  same  procedure  as  has 
just  been  described  for  bringing  down  an  arm  may  be  employed.    This 


DYSTOCIA  ARISING  FROM  PRESENTATIONS  OF  THE  FETUS     715 

desired  object  is  usually  brought  about  by  rotating  the  body  and  with 
it  the  head  of  the  fetus  away  from  the  side  on  which  the  obstructing 
elbow  lies.    This  tends  to  cause  the  fetal  arm  to  slide  to  the  side  of  the 


Fig.  423. — Nuchal  hitch;  arm  behind  neck. 


head.  Thus  in  Fig.  423,  if  the  fetal  trunk  was  rotated  from  left  to  right 
forward,  the  hand  and  forearm  would  slip  along  to  the  right  side  of  the 
head  and  then  the  obstetrician  could  deliver  that  arm  as  already  described. 


Fig.  424. — Mauriceau-Smellie-Veit  method. 


This  rotation  is  facilitated  by  pushing  the  fetus  up  slightly  before  begin- 
ning the  rotation.  The  fetal  head  in  these  different  complications  of 
breech  presentation  is  usually  best  delivered  by  the  Mauriceau-Smellie- 


716        ABNORMAL  LABOR  FROM  ANOMALIES  OF  THE  FETUS 

Veit  method  (Fig.  424),  as  already  described  on  page  305.  With  a  warm, 
wet  towel  over  the  lower  part  of  the  fetal  trunk,  the  fetus  lies  on  the 
forearm  of  the  obstetrician.  Flexion  is  maintained  by  one  or  two  fingers 
in  the  mouth  of  the  fetus  while  traction  is  exerted  on  the  shoulders  by 
two  fingers  of  the  other  hand  on  either  side  of  the  neck.  By  maintaining 
flexion  of  the  head  the  child's  mouth,  nose,  eyes  and  forehead  advance 
over  the  perineum,  the  body  of  the  child  being  raised  and  made  to  ap- 
proach the  abdomen  of  the  mother.  In  cases  of  contracted  conjugate  or 
of  relati^•ely  large  head  difficulty  may  be  met  with  in  extracting  the  fetal 
head.  This  difficulty  is  still  further  increased  if  the  cervix  is  not  suffi- 
ciently dilated  and  emphasizes  the  importance  of  making  sure  that  the 
cervix  is  well  dilated  before  beginning  the  extraction. 

If  the  conjugate  of  the  pelvis  is  shortened,  in  other  words,  if  the  case 
in  hand  is  a  simple  flat  pelvis,  it  will  often  be  found  of  value  to  so  rotate 
the  fetal  body  that  the  long  diameter  of  the  head  as  it  enters  the  brim 
lies  transversely.  It  is  also  an  advantage  to  crowd  the  occiput  as  near 
the  lateral  wall  of  the  pelvis  as  possible  so  as  to  have  the  bitemporal  diam- 
eter opposite  the  narrowest  part  of  the  brim.  Furthermore,  if  marked 
flexion  of  the  head  in  this  transverse  position  is  brought  about  by  the 
fingers  in  the  fetal  mouth,  the  bitemporal  diameter  is  made  to  enter  the 
brim  before  the  biparietal  which  is  larger.  This  gives  the  advantage  of 
the  smaller  end  of  the  wedge  which  is  of  value. 

It  is  not  often  that  the  forceps  are  needed  in  the  delivery  of  the  after- 
coming  head.  Occasionally,  however,  they  are  of  great  assistance  in 
delivering  the  child  within  the  required  time.  If  needed  they  are  applied 
to  the  sides  of  the  child's  head  along  the  occipitomental  diameter,  after 
raising  the  child's  body.  When  studying  the  mechanism  of  breech 
presentation  (see  page  300),  attention  was  called  to  the  fact  that  occasion- 
ally the  occiput  rotated  to  the  hollow  of  the  sacrum  and  that  the  head 
could  then  be  born  by  continued  flexion  or  by  extension.  In  the  hands 
of  the  skilled  obstetrician  these  occipitoposterior  positions  are  usually 
rotated  to  occipito-anterior  positions  and  delivered  as  such.  Neglected 
cases  and  cases  associated  with  certain  unusual  deformities  of  the  pelvis 
may  necessitate  delivery  of  persistent  occipitoposterior  positions  as  such. 

Compound  Presentation. — A  compound  presentation  is  the  presenta- 
tion of  two  or  more  parts  of  the  fetus  at  the  same  time,  as  for  instance 
the  head  and  a  hand;  the  breech  and  a  hand;  the  head  and  a  foot;  a 
transverse  with  two  hands,  or  a  transverse  with  a  hand  and  a  foot,  etc. 

Etiology. — A  compound  presentation  is  usually  associated  with  some 
disproportion  between  the  presenting  part  and  the  pelvic  brim,  so  that 
the  presenting  part  does  not  readily  engage  and  leaves  room  at  its  side 
for  another  fetal  part  to  slip  into  the  pelvis.  This  complication  is  there- 
fore predisposed  to  by  a  contracted  pelvis  or  by  a  head  of  abnormal 
size;  it  is  also  predisposed  to  by  a  lack  of  conformity  of  the  presenting 
part  to  the  brim  of  the  pelvis,  as  in  a  malposition  of  the  fetus;  by  a  dis- 
placed uterus;  by  multiple  pregnancy,  or  by  hydramnios.  It  is  sometimes 
brought  about  mechanically  by  an  unsuccessful  attempt  at  podalic  ver- 
sion in  a  transverse  presentation  with  prolapsed  arm,  a  foot  being  brought 


DYSTOCIA   ARISIXG  FROM   PRESEXTATIOXS  OF   THE  FETUS     717 

down  but.  on  account  of  the  tonic  condition  of  the  uterus,  tlie  prolapsed 
arm  still  remaining  in  the  vagina. 

Frequency. — In  a  series  of  20,000  consecutive  labors  at  the  Sloane 
Hospital  there  were  84  compound  presentations,  i.  e.,  this  complication 
occurred  on  an  average  once  in  every  238  cases.  It  is  more  common  in 
multigravidse  than  in  primigravidse,  as  shown  from  the  fact  that  among 
the  84  cases  there  were  54  multigravidte  and  only  30  primigravidte ;  43 
of  the  84  cases  went  into  labor  prematureh". 

The  frequency  of  the  different  varieties  of  compound  presentation  is 
of  interest.  In  the  above  series  of  84  cases  the  following  frequency'  of 
combination  was  noted: 

Head  with  hand  in  48  cases. 

Breech  with  hand  in  13  cases. 

Head  with  foot  in  10  cases. 

Compound  transverse^  in  7  cases. 

Head  with  hand  and  foot  in  6  cases. 
Treatment. — If  the  diagnosis  is  made  before  rupture  of  the  membranes 
some  authorities  recommend  placing  the  woman  on  the  side  opposite  to 
that  of  the  prolapsed  extremity  in  the  hope  that  the  prolapsed  extremity 
will  be  withdra^^Ti.  Thus,  if  the  right  hand  lies  by  the  side  of  the  present- 
ing head,  place  the  woman  on  her  left  side.  The  author  is  free  to  admit 
that  he  has  never  been  able  to  accomplish  much  by  this  treatment  by 
posture.  The  general  principle  of  treatment  which  he  has  found  most 
useful  in  his  experience  has  been  first  to  endeavor  to  push  up  out  of  the 
way  the  undesired  part  and  then  to  favor  the  descent  of  the  mam  pre- 
senting part.  Failing  either  in  replacing  or  in  keeping  replaced  the 
undesired  part  he  has  generally  considered  version  indicated  unless  the 
procedure  has  been  contra-indicated  by  the  tonic  condition  of  the  uterus 
or  the  firm  engagement  of  the  presenting  parts.  Often  if  the  head  pre- 
sents together  with  one  or  more  extremities  and  the  head  is  engaged, 
the  best  procedure  is  the  application  of  the  forceps  to  the  head,  being 
careful  not  to  include  the  prolapsed  extremity  in  the  grasp  of  the 
instrument,  and  delivery  without  regard  to  the  prolapsed  extremity  or 
extremities.  The  methods  of  treatment  followed  in  the  author's  series 
of  84  cases  are  of  interest  as  showing  the  variety  of  indications  and 
their  results:  26  cases  were  delivered  icithout  a  version  and  of  these  18 
were  delivered  spontaneously,  3  by  breech  extraction,  3  by  forceps,  1 
by  craniotomy  and  1  by  Cesarean  section.  Fifty-eight  were  delivered  hy 
a  version  more  or  less  complete.  After  the  ^'ersion  38  of  these  cases 
delivered  themselves  normally,  18  were  delivered  by  breech  extraction 
and  2  by  the  forceps.  In  32  cases  the  version  was  only  partial,  consisting 
of  little  more  than  the  reposition  of  the  prolapsed  extremity. 

Mortality. — ^The  maternal  mortality  in  this  series  of  84  cases  was  2.3 
per  cent. ;  1  mother  being  lost  from  toxemia  of  pregnancy  and  1  from  a 
rupture  of  the  uterus.  The  fetal  mortality  among  those  A'iable  at  the  time 
of  delivery  was  18.9  per  cent. 

1  A  transverse  vrith  a  prolapsed  hand  is  not  considered  a  compound  presentation  at  the 
Sloane  Hospital,  but  a  transverse  with  two  hands  or  a  hand  and  a  foot  is  so  considered. 


CHAPTER  XXII. 
PROLAPSE  OF  THE  UMBILICAL  CORD. 

TiiK  descent  of  the  umbilical  cord  into  the  pelvis  in  ad\ance  of  the 
presentinjj  part  is  called  a  prolai)se  of  the  cord.  If  diaj2;n()sed  ])efore 
rupture  of  the  membranes  it  is  sometimes  spoken  of  as  presentation  of 
the  cord. 

Frequency. — Different  observers  have  stated  the  frequency  of  prolapse 
of  the  cord  with  very  marked  differences  varying  from  1  in  65  to  1  in 
1897  cases. 

In  20,000  consecuti\-e  deliveries  at  the  Sloane  Hospital  prolapse  of 
the  cord  occurred  in  269,  a  frequency  of  1  in  74  cases,  or  L3  per  cent. 
It  is  therefore  approximately  correct  to  consider  the  frequency  about 
1  per  cent. 

Etiology. — The  chief  cause  of  prolapse  of  the  cord  is  some  lack  of 
adaptation  of  the  presenting  part  to  the  inlet  of  the  pelvis.  With  the 
normal  adaptation  of  the  presenting  part  to  the  lower  uterine  segment 
and  the  brim  of  the  pelvis  there  is  no  room  for  a  loop  of  cord  to  descend 
in  front  of  it.  In  a  malpresentation,  however,  as  in  a  transverse  presen- 
tation, or  in  a  deformed  pelvis  with  pelvic  inlet  too  small  to  allow  the 
entrance  of  a  normal-sized  head,  the  presenting  part  does  not  fit  the 
brim  and  there  is  room  for  a  loop  of  cord  to  descend.  With  this  etio- 
logical principle  understood,  it  is  easy  to  note  associated  causes.  Thus, 
}3rolapse  of  the  cord  is  favored  by  marked  displacements  of  the  uterus; 
deformities  of  the  uterus  as  by  fibromyomata;  hydramnios  in  which  a 
sudden,  profuse  gush  of  liquor  amnii,  especially  if  the  membranes  rup- 
tured in  the  sitting  or  erect  position,  might  wash  down  a  loop  of  cord; 
an  abnormally  long  cord;  a  low  insertion  of  the  cord  as  in  placenta 
previa;  multiparity;  multiple  pregnancy  and  prematurity. 

The  effect  of  some  of  these  causes  may  be  seen  in  the  author's  series 
at  the  Sloane  Hospital.  In  the  269  cases,  184  were  multigravidse  and 
only  85  primigravidse.    There  were  91  premature  deliveries. 

In  the  269  cases  there  were  16(5  whose  presentation  was  not  with 
occiput  anterior.  There  were  67  with  deformed  pehis  and  67  with  abnor- 
mality of  the  cord  or  placenta. 

Diagnosis. — If  the  fetus  is  alive  the  diagnosis  of  a  prolapsed  cord  either 
before  or  after  rupture  of  the  membranes  is  usually  easy  for  a  careful 
observer:  its  cord-like  shape;  its  ])ulsati()n;  its  characteristic  twist,  all 
make  clear  the  condition.  It  should  be  remembered,  h()we\er,  that  the 
the  cord  may  either  present  as  a  loop  with  the  two  limbs  in  apposition  or 
it  may  stretch  across  the  cervical  canal  ))eneath  the  ])resenting  ])art  which 
'(718) 


PROLAPSE  OF   THE   UMBILICAL  CORD  719 

lies  between  the  limbs  of  the  loop.  The  prolapsed  cord  may- even  lie 
outside  the  vulva  and  still  be  pulsating. 

After  pulsation  in  the  cord  has  ceased,  diagnosis  of  its  prolapse  may 
present  difficulties  to  the  beginner.  The  author  was  once  called  to  a 
suburb  of  New  York  to  operate  upon  a  supposed  rupture  of  the  uterus 
with  prolapse  of  the  intestine  through  the  rent  and  cervix.  On  examining 
the  case  he  found  a  prolapsed  cord  of  a  dead  fetus.  The  absence  of 
mesentery  as  well  as  the  characteristics  of  the  cord  made  the  diagnosis 
clear.  It  is  possible  on  superficial  examination  to  mistake  for  a  prolapsed 
cord  of  a  dead  fetus,  part  of  a  foot  or  a  hand  in  the  vagina,  the  edematous 
lip  of  a  lacerated  cervix,  etc.     The  reverse  of  this  is  also  true. 

Prognosis. — ^The  maternal  mortality  depends  upon  the  abnormality 
associated  with  the  prolapse  of  the  cord  and  upon  the  operation  to  which 
the  patient  is  subjected  in  the  attempt  to  save  the  life  of  the  fetus.  The 
mere  existence  of  a  prolapsed  cord,  although  subjecting  the  fetus  to 
grave  danger,  would,  with  a  normal-sized  fetus  and  pelvis,  ordinarily 
cause  little  danger  to  the  mother  if  left  alone,  although  in  rare  cases  the 
prolapse  of  the  cord  might  so  shorten  it  as  to  cause  a  premature  separation 
of  the  placenta. 

In  the  series  of  269  cases  at  the  Sloane  Hospital  there  were  11  maternal 
deaths,  a  mortality  of  4  per  cent.  Of  the  11  cases,  5  died  of  the  toxemia 
of  pregnancy;  3  from  sepsis;  1  from  ruptured  uterus;  1  from  placenta 
previa  and  1  from  abdominal  operation  for  complicating  ovarian  cyst. 
It  should  be  remembered  that  many  of  these  were  neglected  cases  and 
that  in  85,  or  nearly  one-third,  there  was  no  pulsation  in  the  cord  when 
first  seen. 

The  fetal  mortality  from  prolapse  of  the  cord  is  always  high  from 
asphyxia  due  to  the  compression  of  the  cord  between  the  pelvis  and  the 
presenting  part.    It  is  usually  over  50  per  cent. 

As  the  fetal  head  is  much  harder  and  more  closely  fills  the  pelvic  canal 
than  does  the  breech,  the  fetal  mortality  from  prolapse  of  the  cord  with 
a  vertex  presentation  is  about  twice  as  high  as  with  a  breech  presen- 
tation. 

In  the  above  series  of  269  cases  the  fetal  mortality  was  157,  or  58.3 
per  cent.,  although  as  said  above,  in  85  no  pulsation  could  be  detected 
when  first  seen  at  the  hospital.  Of  the  157  fetuses,  29  were  premature 
and  might  be  considered  abortions.  Ninety-seven  were  stillbirths  and 
31  died  subsequently. 

Treatment. — In  the  treatment  of  prolapse  of  the  cord,  prophylaxis 
deserves  first  consideration.  Remembering  that  in  malpresentations, 
deformed  pelves  and  in  hydramnios,  prolapse  of  the  cord  is  common, 
great  care  should  be  taken  that  these  cases  are  not  in  sitting  or 
standing  positions  when  the  membranes  are  likely  to  rupture,  and  that 
if  possible  the  membranes  should  be  kept  intact  until  the  cervix  is  well 
dilated. 

Furthermore,  as  the  prognosis  is  worse  the  longer  the  prolapse  exists, 
in  all  cases,  as  soon  as  the  membranes  rupture,  an  examination  should 
be  made  to  ascertain  the  presence  or  absence  of  the  prolapse. 


720  PROLAPSE  OF   THE   UMBILICAL  CORD 

If  the  prolapse  has  actually  occurred  there  are  two  indications  in  its 
treatment : 

1.  To  replace  the  cord. 

2.  To  maintain  the  reposition. 

For  the  reposition  the  best  plan  is  usually  to  place  the  woman  in  the 
knee-chest  position  under  anesthesia  (some  prefer  the  Trendelenburg 
position)  and  then  with  the  whole  hand  in  the  vagina  and  as  many  fingers 
in  the  cervical  canal  as  will  pass,  to  carry  up  the  prolapsed  cord  on  the 
tips  of  the  fingers  with  as  little  compression  as  possible  and  place  it 
above  some  projecting  portion  of  the  presenting  part  if  it  is  a  vertex  and 
then  withdraw  the  hand  gently.  If  the  cervix  is  not  sufficiently  dilated 
for  this  procedure  and  the  membranes  are  unruptured,  they  should  be 
kept  intact  if  possible  until  the  cervix  is  dilated,  and  for  this  purpose  the 
introduction  of  the  Voorhees  elastic  bag  answers  well. 

During  all  procedures  for  the  reposition  of  a  prolapsed  cord  and  the 
maintaining  of  it  in  the  correct  position,  the  woman  should  be  kept  as 
much  as  possible  with  elevated  hips.  While  she  can  be  kept  for  a  short 
time  in  the  knee-chest  position,  this  soon  becomes  very  tiresome,  and  the 
Trendelenburg  posture,  or  the  exaggerated  lateral  prone  position,  with 
the  woman  on  the  side  corresponding  with  the  fetal  back  and  with  a 
pillow  beneath  her  hips,  may  be  substituted. 

With  the  cervix  dilated  and  the  cord  replaced  manually  it  is  often 
well  in  a  vertex  presentation  to  rupture  the  membranes  and  secure  the 
engagement  of  the  head  by  pressure  from  above  or  by  the  use  of  the 
forceps. 

With  the  rupture  of  the  membranes,  if  the  cord  remains  replaced  and 
the  head  descends,  the  delivery  may  be  left  to  nature  or  expedited  with 
the  forceps,  depending  upon  the  condition  of  the  fetal  heart  which  should 
be  auscultated  every  few  moments.  If  in  a  vertex  presentation  with  the 
rupture  of  the  membranes  the  prolapse  recurs,  or  if  the  membranes  are 
ruptured  when  the  case  is  first  seen,  and  it  is  impossible  to  replace 
the  cord  and  maintain  the  reposition,  the  best  procedure  is  usually  to 
dilate  the  cervix  manually  if  necessary  and  perform  a  podalic  version, 
provided  version  is  not  contra-indicated  by  a  tonic  uterus.  If  version 
is  contra-indicated,  the  cord  should  be  placed  where  its  compression 
is  likely  to  be  least,  as  opposite  one  of  the  sacro-iliac  joints,  and  then 
the  child  deli\'ered  by  the  forceps  as  rapidly  as  is  consistent  with  the 
safety  of  the  mother. 

If  the  presentation  which  is  complicated  by  a  prolapse  of  the  cord  is 
a  breech  and  the  cervix  is  well  dilated  the  indication  is  to  pull  doAvn  one 
foot  and  hasten  the  extraction.  If  the  cervix  is  not  well  dilated,  a  large- 
sized  elastic  bag  should  be  introduced  so  that  when  this  passes  the  cervix 
the  labor  can  easily  be  terminated  rapidly.  In  this  case  as  in  a  vertex 
presentation  the  fetal  heart  should  be  auscultated  frequently,  as  this 
alone  gives  the  criterion  of  the  fetal  condition,  which  serves  as  a  guide 
to  treatment. 

If  the  fetal  heart  has  ceased  to  pulsate,  the  method  of  delivery  should 
be  selected  which  will  expose  the  mother  to  the  least  risk,  either  leaving 


PROLAPSE  OF   THE   UMBILICAL  CORD 


721 


the  case  to  nature  or  expediting  by  forceps  or  version.  It  is  seldom 
that  any  other  instrument  than  the  hand  is  needed  for  the  reposition  of 
a  prolapsed  cord.  If  such  an  instrument  is  needed,  one  of  the  best  can 
be  improvised  by  running  a  loop  of  tape  through  a  gum  elastic  catheter 
(see  Fig.  425).    The  loop  of  tape  emerging  from  the  eye  of  the  catheter 


Fig.  425 


Fig.  426 


Fig.  427 


can  be  passed  around  the  loop  of  cord  and  then  hooked  over  the  end  of 
the  catheter.  So  long  as  the  catheter  is  passed  in  the  upward  direction 
(see  Fig.  426)  the  tape  carries  the  loop  of  cord.  When  the  catheter  is 
drawai  downward  the  tape  slips  off  the  end  and  the  umbilical  cord  is 
released  (see  Fig.  427). 


46 


PART  y. 
OBSTETRIC  SURGERY. 


CHAPTER  XXIII. 
INJURIES  TO  THE  PARTURIENT  CANAL. 

Laceration  of  the  Cervix. — Slight  lacerations  of  the  cervix  are  common 
accompaniments  of  a  first  labor,  even  of  one  called  normal,  but  these 
slight  lacerations  usually  heal  readily  if  cleanliness  is  observed,  and  only 
leave  small  cicatrices  which  usually  distinguish  the  parous  women  from 
the  nullipara.  The  slight  lacerations  may  be  unilateral,  bilateral  or 
stellate,  thus  superficially  dividing  the  ring  of  cervix  about  the  external 
OS.  The  result  may  be  a  slightly  patulous  condition  of  the  cervical 
opening,  but  unless  infection  has  occurred  the  slight  lacerations  are 
unimportant  and  require  no  treatment. 

Extensive  lacerations  of  the  cervix,  on  the  other  hand,  may  be  of  marked 
importance,  both  at  the  time  of  delivery  and  subsequently.  These 
lacerations,  like  the  slight  ones  just  described,  may  be  unilateral,  bilateral 
or  stellate,  and  in  rare  cases  may  even  be  transverse.  Cases  are  reported 
by  Boudereau,  Edgar  and  others  in  which  the  cervix  has  been  com- 
pletely torn  off  from  the  rest  of  the  uterus. 

The  deep  lacerations  are  usually  longitudinal  and  either  unilateral 
or  bilateral.  The  longitudinal  lacerations  may  extend  upward  and 
become  a  part  of  a  rupture  of  the  lower  uterine  segment,  or  even  open 
the  peritoneal  cavity.  It  may  extend  downward  and  involve  the  vagina, 
perhaps  opening  the  rectum. 

Etiology. — Laceration  is  predisposed  to  by  an  abnormal  rigidit}'  of  the 
cervix;  a  disproportion  between  the  presenting  part  and  the  parturient 
canal;  a  premature  rupture  of  the  membranes  and  a  rapid  artificial 
delivery. 

The  long,  narrow,  rigid  cervix  of  the  poorly  developed  uterus  dilates 
slowly  and  often  tears  in  spontaneous  labors  and  is  usually  torn  if,  as 
so  frequently  happens,  the  woman  has  to  be  delivered  by  the  forceps.  It 
is  this  very  rigid  cervix,  especially  in  elderly  primigravidse,  which  has 
usually  furnished  the  cases  of  circular  detachment  of  the  cervix  from  the 
rest  of  the  uterus.  As  a  rule  in  precipitate  labors  the  cervix  dilates  easily 
and  rapidly;  in  fact,  may  have  been  partially  dilated  for  several  weeks 
prior  to  the  onset  of  labor,  and  in  these  cases  laceration  is  unusual. 

(723) 


724  INJURIES   TO   THE  PARTURIENT  CANAL 

It  is  in  tlie  tedious  labors,  especially  with  premature  rupture  of  the 
membranes  where  the  cervix  becomes  edematous,  that  laceration  is 
common. 

It,  moreover,  is  especially  common  where  the  labor  has  to  be  terminated 
artificially,  as  by  a  difficult  forceps  operation  or  a  version. 

The  operation  of  accouchement  force  is  usually  associated  with  more 
or  less  laceration,  and  if  the  cervix  is  long  and  rigid  the  tearing  is  often 
deep.  When  the  head  is  delivered  either  in  the  course  of  a  version  or 
a  forceps  delivery  the  laceration  is  apt  to  be  deepened. 

Symptoms  and  Diagnosis.— In  the  majority  of  cases  there  are  no  symp- 
toms during  the  puerj)erium  from  laceration  of  the  cervix  and  the  diag- 
nosis is  made  by  the  vaginal  examination  at  the  end  of  the  obstetric 
month  which  detects  the  irregular  shape  of  the  cervix.  There  may,  how- 
ever, be  one  pronounced  symptom  of  the  laceration  immediately  after 
the  birth  of  the  child,  and  continuing  after  the  expulsion  of  the  placenta, 
and  that  is  hemorrhage. 

As  a  rule  the  pressure  of  the  presenting  part  prevents  bleeding  until 
after  the  child  is  born  and  then  it  must  be  distinguished  from  ordinary 
postpartum  hemorrhage  with  relaxed  fundus. 

The  condition  of  the  fundus  is  the  usual  criterion.  Hemorrhage, 
associated  with  a  firm,  well-contracted  fundus,  usually  means  laceration 
of  the  parturient  canal,  and  the  site  is  determined  by  inspection.  If  no 
bleeding  is  seen  to  come  from  the  perineum,  lower  vagina  or  anterior 
portion  of  the  vulva,  the  cervix  can  be  pulled  down  with  a  vulsella  and 
inspected  as  shown  in  Fig.  428. 

Treatment. — The  question  of  immediate  repair  of  a  lacerated  cervix 
has  during  the  last  few  years  been  the  subject  of  much  discussion. 
Obstetricians  are  pretty  well  agreed  that  save  for  the  one  indication — 
hemorrhage — a  lacerated  cervix  had  better  not  be  repaired  immediately 
after  labor. 

The  reasons  for  this  conclusion  are  numerous.  In  the  first  i)lace,  if 
the  delivery  has  been  conducted  in  an  aseptic  manner,  many  of  the 
lacerations  will  heal  in  such  a  way  as  to  be  the  cause  of  no  further  trouble. 

Furthermore,  the  condition  of  the  parts  immediately  after  labor  is  a 
poor  one  for  repair.  The  parts  are  edematous  and  the  landmarks  more 
or  less  obscured.  It  is  difficult  to  tell  how  small  to  make  the  os,  and 
because  of  these  difficulties,  in  many  cases  the  cervix  has  been  closed 
too  tightly,  the  retention  of  the  lochia  has  occurred  and  sepsis  has 
resulted. 

It  may  be  asked,  so  long  as  it  is  always  recommended  to  rei)air  a 
laceration  of  the  perineum  immediately.  Why  should  not  a  laceration  of 
the  cervix  be  repaired  at  once?  The  conditions  are  different  in  the  two 
cases  and  the  differences  depend  chiefly  upon  two  things — drainage 
and  the  amount  of  handling.  The  ordinary  repair  of  a  lacerated  i)eri- 
neum  interferes  little  with  drainage  from  the  uterus.  The  repair  of  a 
lacerated  cervix,  in  which  the  closure  is  too  tight,  may  interfere  with  or 
even  obstruct  uterine  drainage. 

Furthermore,  the  drawing  down  of  the  cervix  and  the  amount  of 


LACERATIONS  OF  THE  VAGINA 


725 


manipulation  necessary  in  its  repair  exposes  the  woman  to  a  risk  of  infec- 
tion much  greater  than  that  associated  with  a  perineorrhaphy. 

On  the  other  hand,  a  laceration  of  the  cervix  causing  hemorrhage  indi- 
cates operation.  While  it  is  a  fact  that  if  the  vessel  in  the  cervix  which 
is  bleeding  is  a  small  one,  the  packing  of  the  uterine  cavity,  the  cervical 
canal  and  the  vagina  firmly  with  gauze  will  in  many  cases  check  the 
hemorrhage,  in  most  cases  this  is  an  uncertain  procedure,  and  the 
better  plan  is  to  expose  the  cervix  as  shown  in  Fig.  428  and  suture 
the  tear  or  tears  with  chromicized  catgut,  being  careful  to  insert  the  first 
suture  at  the  upper  angle  of  the  tear  which  is  usually  the  source  of  the 
bleeding,  and  bearing  in  mind  the  danger  of  leaving  too  narrow  a  cervical 
canal. 


Fig.  428. — Showing  a  recent  cervical  tear.     (Bumm.) 


The  use  of  an  absorbable  suture  like  chromicized  catgut,  which  holds 
the  tissues  in  apposition  until  union  is  complete,  but  does  not  subject  the 
patient  to  the  annoyance  of  removal,  is  a  distinct  advantage,  as  can  be 
readily  appreciated  by  all  who  have  tried  both  the  absorbable  and  the 
non-absorbable  suture. 

Lacerations  of  the  Vagina. — The  most  common  site  of  a  vaginal 
laceration  is  in  the  lower  portion  of  the  canal,  and  it  is  usually  associated 
withja  laceration  of  the  perineum,  the  tear  being,  as  a  rule,  longitudinal  and 
extending  either  in  the  median  line  or  on  one  or  both  sides  of  the  vagina. 
If  the  vaginal  tear  is  bilateral,  the  two  sides  of  the  tear  are  often  of 
unequal  length  with  a  tongue  of  intact  mucosa  between  them. 


726  INJURIES   TO    THE   PARTURIENT   CANAL 

These  lower  vaginal  tears,  aside  from  being  caused  l)y  the  same  condi- 
tions which  produce  lacerations  of  the  perineum,  are  often  caused  by 
the  tips  of  the  forceps  blades,  especially  if  the  handles  are  elevated,  and 
thus  the  tips  depressed  too  soon. 

The  next  most  frequent  site  of  a  vaginal  tear  is  in  the  upper  part  of 
the  canal,  and  is  usually  an  extension  of  a  cervical  tear.  These  tears  may 
be  either  longitudinal  or  transverse,  in  some  cases  separating  the  vagina 
from  the  cervix  for  a  considerable  distance.  These  vaginal  tears  may 
be  slight  and  of  little  consequence,  or  they  may  be  extensive,  going 
through  into  either  the  bladder  or  the  rectum.  The  openings  into  the 
bladder  and  rectum,  however,  wdiich  occasionally  follow  delivery  are 
usually  the  result  of  long  pressure  from  the  presenting  part  with  slough- 
ing; the  fistulae  resulting  from  pressure  necrosis  rather  than  from 
tearing. 

Lacerations  of  the  middle  portion  of  the  vagina  are  unusual  but  occa- 
sionally occur  either  from  unskilled  use  of  the  forceps  or  rarely  in  an 
unaided  labor. 

Treatment. — Lacerations  of  the  lower  portion  of  the  vagina  should 
always  be  searched  for  when  examining  for  lacerations  of  the  perineum 
and  should  be  sutured. 

Lacerations  in  the  upper  portion  of  the  vagina,  like  lacerations  of  the 
cervix,  should,  as  a  rule,  be  left  alone  unless  hemorrhage  occurs,  and 
usually  union  takes  place.  Frequently  even  fistula?  of  bladder  or  rectum 
will  close  spontaneously,  but  if  not  they  should  be  closed  by  operation 
later.  The  obstetric  month  is  usually  not  the  best  time  for  these 
operations. 

Lacerations  of  the  Perineum  and  Vulva. — In  spite  of  all  care  on  the 
part  of  the  obstetrician  laceration  of  the  perineum  will  occasionally  occur. 
Li  the  hands  of  the  skilled  obstetrician  the  lacerations  will  be  relatively 
few  and  not  extensive,  but  in  some  cases  the  condition  of  the  tissue  is 
such  that  it  will  not  sufficiently  stretch  and  a  laceration  occurs.  It  was 
formerly  considered  a  marked  reflection  upon  an  obstetrician's  ability 
or  care  if  a  laceration  occurred,  and  consequently  there  was  a  temptation 
not  to  examine  carefully,  but  if  no  laceration  appeared  externally,  to 
state  the  absence  of  laceration  and  receive  the  credit.  Unfortunately 
the  tears  within  the  vuh'a  which  involve  the  fascia,  binding  together 
the  levatores  ani  muscles,  are  often  more  serious  than  the  external 
tears  and  not  infrequently  a  woman  who  was  told  that  she  had  no  lacera- 
tion, would  find  on  examination  by  a  gynecologist  after  months  of 
discomfort,  that  she  had  had  an  internal  laceration  which  had  not  been 
recognized  by  her  obstetrician,  and  then  his  early  credit  was  changed 
to  later  and  more  lasting  blame. 

The  laity  have  gradually  become  educated  to  the  fact  that  lacera- 
tions of  the  perineum  will  occasionally  occur  in  the  best  of  hands  and 
the  obstetrician  to  be  blamed  is  usually  not  the  one  in  whose  hands  the 
laceration  occurs,  provided  he  properly  repairs  it,  but  the  one  who,  hav- 
ing had  a  laceration,  does  not  examine  carefully  and  ascertain  the  fact, 
but  neglects  it. 


LACERATIONS  OF  THE  PERINEUM  AND   VULVA  727 

Lacerations  of  the  perineum  vary  greatly  in  extent  and  character. 
In  a  primipara  there  is  often  a  slight  tear  of  the  fourchette  perhaps  a 
centimeter  in  length,  but  if  this  involves  only  mucosa  and  neither  muscle 
nor  fascia,  it  is  of  little  consequence  and  will  heal  sufficiently  spon- 
taneously. 

In  general  two  varieties  of  laceration  of  the  perineum  are  recognized: 
the  complete  and  the  incomplete.  The  complete  laceration  passes 
through  the  sphincter  ani,  while  in  the  incomplete  laceration  the 
sphincter  is  not  involved. 

The  complete  laceration  is  fortunately  rare  and  is  excusable  only  in 
very  trying  cases,  as  for  instance,  a  breech  presentation  with  extended 
legs.  In  this  case  the  laceration  is  often  produced  by  the  operator's 
arm.  The  incomplete  laceration,  as  already  stated,,  is  common.  It  may 
be  a  median  tear  extending  from  the  fourchette  downward  toward  the 
anus  and  upward  in  the  median  line  of  the  vagina,  or  it  may  be  a 
lateral  tear  extending  upward  on  one  or  both  sides  of  the  vagina,  as 
already  mentioned  under  Lacerations  of  the  Vagina.  In  rare  cases  the 
tear  has  been  central,  the  fetal  head  passing  through  the  centre  of  the 
perineum  between  the  rectum  and  vagina. 

A  type  of  laceration  often  overlooked  until  months  after  labor  is  the 
submucous  laceration,  in  which  the  lesion  is  in  the  submucous  tissue 
and  the  result  is  a  very  lax  perineum  and  vulvar  outlet  often  associated 
with  a  rectocele  and  cystocele.  The  excessively  relaxed  vulva  sometimes 
arises  as  a  result  of  efforts  to  prevent  visible  laceration  of  the  perineum, 
the  head  in  the  second  stage  of  labor  being  held  back  until  the  perineum 
and  vulva  have  become  so  overstretched  that,  although  no  visible  lacera- 
tion occurs,  the  pelvic  floor  never  regains  its  tone.  These  are  cases  in 
which  the  after-result  to  the  patient  would  have  been  better  with  a 
repaired  laceration  than  with  no  visible  laceration  but  no  tone. 

Treatment. — Prophylactic. — 'No  discussion  of  the  treatment  of  lacera- 
tion of  the  perineum  is  complete  without  consideration  of  the  prophyl- 
axis, i.  e.,  the  method  of  preserving  the  integrity  of  the  pelvic  floor 
during  the  birth  of  the  child.  This  is  included  in  the  proper  manage- 
ment of  the  second  stage  of  labor  and  consists  of  the  following  endeavors 
on  the  part  of  the  obstetrician: 

L  To  control  the  advance  of  the  presenting  part  so  that  it  will  be 
gradual  and  the  dilatation  will  be  gradual  and  complete. 

2.  To  keep  the  shortest  diameter  of  the  presenting  part  across  the 
parturient  canal.  This  in  a  vertex  presentation  implies  keeping  the 
head  well  flexed  until  the  suboccipitobregmatic  diameter  has  passed 
the  pelvic  outlet  before  extension  is  allowed. 

3.  To  deliver  the  presenting  part  gradually  in  the  interval  between 
uterine  contractions,  the  patient's  expulsive  efforts  being  controlled  by 
anesthesia. 

Oyeratim. — If  a  laceration  of  the  perineum  has  occurred,  the  indica- 
tion in  all  cases  save  those  in  which  the  woman  is  in  very  grave  shock 
is  its  immediate  repair.  If  strict  cleanliness  is  observed  the  tissues  usually 
unite  readily  and  the  woman  is  not  only  saved  the  mental  and  physical 


728  INJURIES   TO   THE  PARTURIENT  CANAL 

distress  of  subsequent  operation,  but  the  increasing  discomfort  of  the 
relaxed  ])elvic  floor  which  finally  compels  her  to  consent  to  this  procedure. 

The  method  varies  according  as  the  laceration  is  incomplete  or  com- 
plete. As  the  former  is  so  much  more  common  than  the  latter,  it  will  be 
discussed  first. 

The  problem  is  to  bring  in  apposition  the  parts  which  were  in  apposi- 
tion when  the  laceration  occurred.  In  order  to  ascertain  just  the  extent 
and  location  of  the  tear  or  tears,  it  is  necessary  to  have  a  good  light 
and  to  separate  the  labia  well  with  the  fingers  of  one  hand  and  with  the 
other  to  sponge  with  sterile  gauze  or  cotton  any  bleeding  surface. 

It  is  important  in  the  first  place  to  see  the  upper  angle  of  the  lacera- 
tion, for  unless  this  is  sutured  the  closure  of  the  lower  portion  only  leaves 
a  pocket  above  in  which  the  lochia  accumulates  and  the  woman  is  exposed 
to  the  risk  of  infection.  The  parts  immediately  after  labor  are  benumbed 
from  the  stretching  and  pressure  and  often  no  anesthetic  is  required  for 
the  suturing.  If  anesthesia  is  required,  it  should  be  borne  in  mind  that 
even  in  a  woman  with  normal  liver  and  kidneys,  chloroform  after  the 
straining  of  the  labor  is  over  is  not  as  safe  as  during  the  labor,  and  not 
as  safe  as  ether.  Not  infrequently  a  slight  superficial  laceration  can  be 
repaired  before  the  placenta  is  expelled  and  while  its  separation  is  being 
waited  for.  For  any  extensive  laceration,  howe^'er,  it  is  better  to  wait 
until  the  placenta  is  expelled  and  ergot  has  been  given.  While  it  is  a 
great  convenience  to  have  an  assistant  administer  the  anesthetic,  circum- 
stances very  frequently  arise  where  it  is  desirable  to  avoid  the  formality 
of  an  operation,  and  usually  when  the  laceration  is  incomplete,  the 
obstetrician  and  his  nurse  should  be  able  to  do  all  that  is  necessary  for 
a  successful  repair.  With  the  patient  across  the  bed,  or  on  a  table,  to 
secure  a  good  view  of  the  field  of  operation,  with  the  knees  supported 
with  a  leg-holder  as  shown  in  Fig.  457  and  with  the  hips  on  a  Kelly  pad 
or  rubber  sheet  leading  to  a  drainage  tub,  the  nurse  with  one  hand 
can  guard  the  fundus  to  prevent  relaxation,  and  with  the  other  can 
administer  the  anesthetic. 

In  suturing  the  tears  in  the  vaginal  sulci,  the  repair  of  which  is  very 
important  for  the  future  tone  of  the  pelvic  floor,  it  is  well  to  introduce 
the  needle  in  the  vaginal  mucosa  on  one  side  of  the  tear,  direct  it  slightly 
toward  the  operator,  have  it  emerge  at  the  bottom  of  the  tear,  reintro- 
duce it  near  the  point  of  exit,  direct  it  slightly  from  the  operator,  and 
have  it  emerge  on  the  vaginal  mucosa  opposite  its  point  of  entrance. 
Introduce  each  succeeding  suture  in  the  lateral  sulcus  or  sulci  in  the 
same  manner. 

After  repairing  the  lateral  tears  there  remains  only  the  laceration 
at  the  fourchette  and  the  skin  perineum  to  be  sutured.  The  most 
important  stitch  here  is  the  so-called  crown  stitch  which  brings  together 
the  parts  at  the  fourchette,  the  remaining  sutures  being  merely  super- 
ficial. In  private  practice  the  best  suture  material  for  the  repair  of 
incomplete  lacerations  of  the  perineum,  as  for  repair  of  lacerations  of 
the  cervix,  is  20-day  chromicized  catgut,  which  holds  the  tissue  in  apposi- 
tion long  enough  for  firm  union,  yet  does  not  subject  the  patient  to  the 
annoyance  of  having  the  stitches  removed.    In  a  hospital-ward  service. 


COMPLETE  LACERATIOX  OF   THE  PERINEUM 


'29 


for  purposes  of  economy  it  is  sometimes  advisable  to  suture  tears  in  the 
vagina  and  about  the  vestibule  with  plain  catgut,  and  for  repair  of  the 
perineal  body  and  skin  to  use  silkworm-gut  sutures. 

If  the  laceration  has  extended  into  the  bulb  of  the  vestibule  and  is 
causing  considerable  bleeding,  the  best  plan  is  to  surromid  the  bleeding 
area  with  a  purse-string  suture,  which  passes  in  and  out  of  the  surround- 
ing tissue.  AYhen  this  is  drawn  up  and  tied  it  usually  so  constricts  the 
bleeding  area  as  to  check  all  hemorrhage. 

In  certain  difficult  cases.,  as  with  impacted  breech  with  extended  legs 
in  an  elderly  primigravida,  a  complete  laceration  of  the  perineum  will 
occasionallv  occur  in  the  effort  of  the  obstetrician  to  deliver  a  living 


Fig.  429. — Denudation  for  secondary  iLpair  of  complete  laceration  of  perineum. 

child.      In  20,000  consecutive  deliveries  at  the  Sloane  Hospital  there 
were  17  complete  lacerations,  or  1  in  1176. 

^^  hen  this  accident  has  occurred  it  is  usually  advisable  to  attempt 
its  repair  at  once,  although  it  may  not  in  every  case  be  absolutely  suc- 
cessful, the  distress  to  the  woman  from  an  ununited  sphincter  with  lack 
of  control  of  feces  and  gas  being  so  great  that  every  safe  effort  should 
be  made  to  save  her  from  this  annoyance.  In  some  cases  of  complete 
laceration  of  the  perineum,  nature  by  filling  in  the  gap  between  the  ends 
of  the  sphincter  with  cicatricial  tissue,  will  give  the  woman  partial  con- 
trol, although,  as  a  rule,  the  result  is  so  imperfect  as  to  be  very  unsatis- 
factory and  not  to  be  relied  upon.  Certainly  the  indication  is  to  repair 
by  operation. 


730 


IXJIRIES    TO    THE   PARTURIEST   (A SAL 


In  a  complete  laceration  of  the  perineum  it  i>  u>ually  a(hisal)le  to 
secure  the  services  of  an  assistant  to  administer  the  anesthetic,  so  that 
the  nurse  will  be  left  free  to  assist  the  operator.  The  operation  which 
has  given  the  author  the  greatest  satisfaction  in  the  repair  of  complete 
lacerations  is  based  upon  the  principle  advocated  by  Xoble.  of  Georgia, 
by  which  the  anterior  rectal  wall  is  drawn  down  far  enough  to  keep  the 
rectal  contents  away  from  the  perineal  wounrl. 

The  technic  can  perhaps  be  best  understood  by  referring  to  the 
illustrations  of  the  secondary  repair  of  complete  lacerations  as  performed 
by  the  author  (see  Figs.  429,  430.  and  431).  In  the  immediate  repair  the 
tissues  are  eflematous  and  the  landmarks  are  somewhat  obscured,  but  the 


Fig.  430. — Repair  of  complete  laceration  of  perineum.    Drawing  down  anterior  rectal  wall. 

ends  of  the  sphincter  are  not  as  much  retracted.  On  the  other  hand,  in 
the  secondary  operation,  the  original  raw  surface  must  be  restored  by 
denudation  and  the  ends  of  the  sphincter  freed  and  brought  forward.  In 
both  operations  the  anterior  wall  of  the  rectal  tube  .should  be  freed  and 
drawn  downward,  with  an  artery  clamp  applied  to  it,  until  the  ends  of  the 
sphincter  ani  can  be  united  over  it  as  shown  in  Figs.  429  and  430.  The 
ends  of  the  sphincter  are  united  by  chromicized  catgut,  two  stay  sutures  of 
silkworm  gut  being  introducerl  from  the  skin  surface  through  the  sphincter 
at  a  little  distance  from  the  sutured  ends  to  serve  as  a  kind  of  splint  and 
additional  support.  When  these  are  tied  (see  Fig.  431  )  there  is  left  for 
repair  only  what  would  correspond  to  an  incomplete  laceration  of  the  peri- 


COMPLETE  LACERATION  OF  THE  PERINEUM  731 

neum  which  may  be  repaired  in  the  usual  way.  The  bowels  should  be  kept 
constipated  for  three  full  days  and  then  moved  with  great  care  and  with- 
out straining.  The  author's  usual  method  is  to  keep  the  patient  on  broths 
during  the  first  three  days  following  the  operation,  avoiding  milk  which 
is  apt  to  cause  a  constipated  stool.  On  the  night  of  the  third  day  a 
laxative  pill  is  given,  and  on  the  morning  of  the  fourth  day  through  a 
catheter  an  enema  of  olive  oil,  §iv,  is  carefully  given  and  allowed  to 
remain  and  soften  the  stool.  A  teaspoonful  of  Rochelle  or  Epsom  salts 
is  then  given  by  mouth  every  hour,  until  the  bowels  move  or  until  eight 
doses  have  been  taken.  If  necessary  a  soapsuds  enema  is  then  adminis- 
tered through  a  catheter  to  start  the  movement,  the  patient  being 


Fig.  4.31. — Repair  of  complete  laceration  of  perineum.     Sutures  introduced. 

cautioned  against  straining.  After  the  first  movement  the  bowels  may 
be  moved  each  day.  The  silkworm-gut  sutures  should  be  removed  at 
the  end  of  about  ten  days. 

In  considering  the  different  procedures  available  for  dealing  with 
dystocia  the  author  wishes  first  to  present  the  three  non-cutting  opera- 
tions : 

1.  Induction  of  premature  labor.    See  Chapter  XXIV. 

2.  The  use  of  the  forceps.    See  Chapter  XXV,  page  745. 

3.  Version.     See  Chapter  XXVI,  page  768. 

The  operations  involving  the  use  of  the  knife  will  be  considered  in 
Chapter  XXVII,  page  776. 


CHAPTER    XXIV. 
INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR. 

The  course  of  pregnancy  may  be  artificially  interrupted  in  the  interest 
of  either  the  mother  or  the  child,  or  both. 

If  the  pregnancy  is  interrupted  before  the  child  is  viable,  /.  c,  before 
it  is  capable  of  life  and  growth  outside  of  the  uterus,  the  procedure  is 
called  inchwticm  of  abortion. 

If  the  interruption  is  brought  about  after  the  child  is  ^'iable,  it  is  called 
induction  of  'premature  labor. 

The  period  of  viability  of  the  child  is  therefore  the  di\i(ling  line 
between  them.  The  procedures  of  induction  of  abortion  and  induction 
of  premature  labor  are  so  closely  related  that  they  will  both  be  con- 
sidered in  the  same  chapter.  There  is,  however,  one  marked  difference 
between  them.  Induction  of  abortion  is  performed  solely  in  the  interest 
of  the  mother,  and  the  life  of  the  fetus  is  disregarded.  Induction  of  pre- 
mature labor,  on  the  other  hand,  usually  carries  with  it  the  assumption 
that  the  fetus  is  capable  of  existence  outside  of  the  uterus  and  the  opera- 
tion is  performed  in  the  interests  of  both  mother  and  child;  the  excep- 
tion being  induction  of  premature  labor  when  the  child  is  dead,  late  in 
pregnancy. 

INDUCTION    OF   ABORTION. 

^Yllen  the  further  continuance  of  gestation  would  seriously  endanger 
the  life  or  future  health  of  the  mother,  it  is  justifiable  to  induce  al)ortion 
in  the  interest  of  the  mother. 

Indications. — The  indication  may  be  maternal  or  fetal. 

Maternal. — These  may  be  general  or  local. 

(ieneral  Indications. — The  most  common  maternal  indication  for 
induction  of  abortion  is  some  form  of  to.vemia.  It  may  show  itself  in 
the  form  of  pernicious  vomiting  with  evidently  a  liver  lesion,  marked 
acidosis,  etc.,  or  it  may  assume  the  form  of  a  progressively  increasing 
kidney  disturbance  with  marked  albuminuria,  high-tension  pulse,  head- 
ache, edema,  etc.  Certain  it  is  that  a  toxemia,  increasing  in  spite  of 
treatment,  is  the  most  common  indication  justifying  induction  of  abortion. 

The  indication  may  arise  from  advanced  yuhnonary  or  cardiac  disease. 
When  discussing  tuberculosis  and  cardiac  disease  complicating  pregnancy 
(see  pages  459  and  463)  the  author  made  his  position  clear,  that  in  an 
active  tuberculosis  he  believed  that  pregnancy  should  not  be  allowed 
to  continue.  Also,  that  in  certain  cases  of  cardiac  disease,  especially  in 
cases  of  mitral  stenosis  where  failure  of  compensation  had  been  present 
before  pregnancy  started,  interruption  of  the  pregnancy  was  justifial)le. 
( 732 ) 


INDUCTION  OF  ABORTION  733 

The  indication  for  induction  of  abortion  may  lie  in  the  nervous  system 
of  the  mother  as  a  chorea,  mania,  or  melancholia.  It  is  well  known  that 
a  woman  who  has  been  subject  to  attacks  of  chorea  has  a  tendency  to 
a  recurrence  of  it  in  pregnancy.  The  chorea  in  some  cases  assumes  such 
a  severe  form  as  to  cause  an  abortion,  and  in  other  cases  in  the  interests 
of  the  mother  it  is  necessary  to  induce  an  abortion.  The  question  of 
mania  and  melancholia  complicating  a  pregnancy  and  serving  as  an 
indication  for  its  interruption  is  a  very  important  one. 

The  disappointment  at  finding  herself  pregnant  is  sometimes  so  great 
in  a  woman  that  for  the  time  being  it  may  assume  the  character  of  a 
melancholia.  In  the  majority  of  these  cases,  moral  suasion  and  sym- 
pathy on  the  part  of  the  friends  and  will-power  and  common-sense  on 
the  part  of  the  woman  herself  will  enable  her  to  adjust  herself  to  the 
circumstances  and  the  pregnancy  continues  without  further  trouble. 
Occasionally,  however,  a  true  melancholia  or  mania,  even  with  homicidal 
tendencies,  develops  and  unless  this  soon  subsides  under  treatment 
directed  toward  a  toxemia  and  with  nerve  sedatives,  the  future  men- 
tality of  the  woman  demands  an  interruption  of  the  pregnancy.  One 
of  the  difficult  problems  is  sometimes  to  determine  whether  the  mental 
condition  is  feigned  or  real.  If  the  abnormal  mental  condition  is  real 
and  distinctly  pathological,  especially  if  it  shows  a  homicidal  tendency, 
the  pregnancy  should  be  interrupted. 

Certain  blood  conditions  of  the  mother,  such  as  a  pernicious  anemia, 
in  which  pregnancy  seems  to  be  hastening  the  fatal  termination,  justify 
induction  of  abortion. 

In  general  it  may  be  said  that  when  the  condition  of  the  mother  is 
such  that  her  life,  future  health,  or  reason,  are  seriously  endangered 
by  a  continuance  of  a  pregnancy,  that  pregnancy  should  be  inter- 
rupted. 

Local  Indications. — Certain  local,  pathological  conditions  in  the 
mother  occasionally  justify  the  interruption  of  a  pregnancy. 

If  a  woman  has  a  carcinoma  of  the  uterus  in  the  operable  stage,  so 
important  is  it  that  the  disease  should  be  removed  early  and  radically, 
that  the  presence  of  a  pregnancy  should  be  disregarded  entirely.  If  the 
carcinoma  is  in  the  inoperable  stage  and  the  pregnancy  near  term,  the 
life  of  the  fetus  deserves  consideration. 

When  Cesarean  section  carried  with  it  a  high  mortality,  there  were 
many  local  conditions  in  a  woman's  pelvic  organs  or  the  parturient  canal 
which  were  considered  justifiable  indications  for  induction  of  abortion. 
Thus,  if  a  woman  had  a  pelvis  too  contracted  to  allow  of  delivery  of  a 
child  by  forceps  or  a  version,  it  was  formerly  considered  justifiable  to 
interrupt  the  pregnancy.  If  a  woman  had  a  fibroid  tumor  which  was 
likely  to  grow  during  pregnancy  and  perhaps  require  a  Cesarean  section 
with  a  hysterectomy  or  a  myomectomy,  it  was  formerly  considered 
justifiable  to  interrupt  the  pregnancy.  With  the  present  low  mortality 
of  Cesarean  section,  even  when  coupled  with  a  hysterectomy  or  myo- 
mectomy, it  is  today  usually  not  considered  justifiable  to  interrupt  a 
pregnancy  under  these  circumstances  unless  the  general  condition  of 


734        INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR 

the  woman  is  such  as  to  make  her  an  unsafe  surgical  risk  for  any 
abdominal  ojjeration. 

Fetal  Indications. — Certain  grave  conditions  of  the  fetal  membranes 
or  the  placenta  indicate  induction  of  abortion.  Among  these  may  be 
mentionefl : 

Hydatidiform  mole. 

Acute  hydramnios. 

Placenta  previa. 

Premature  separation  of  a  normally  situated  placenta — accidental 
hemorrhage. 

These  are  all  discussed  elsewhere,  but  it  is  a  well-established  fact 
that  in  the  case  of  a  hydatidiform  mole  the  early  emptying  of  the 
uterus  is  the  best  procedure,  not  only  for  the  immediate  welfare  of 
the  woman,  but  to  save  her  from  uterine  perforation  and  the  possible 
development  of  chorio-epithelioma.  In  acute  hydramnios,  placenta 
previa  and  "accidental  hemorrhage,"  while  the  treatment  varies  with 
the  variety  and  degree  of  the  condition  present,  the  generally  accepted 
treatment  for  the  severe  types  of  all  three  complications  is  that  of 
emptying  the  uterus. 

Fetal  Death. — While  fetal  death  is  often  the  result  of  maternal  causes, 
it  may  be  looked  upon  as  of  itself  an  occasional  indication  for  induction 
of  abortion.  As  a  rule  the  fetus  after  its  death  in  utero  plays  the  part 
of  a  foreign  body,  upon  which  the  uterus  soon  contracts  and  before 
long  expels.  In  the  meantime,  if  the  amniotic  sac  is  intact,  the  uterine 
contents  are  usually  sterile,  and  no  harm  results  even  if  the  fetus,  her- 
metically sealed,  has  been  retained  in  utero  for  several  weeks.  Occa- 
sionally, however,  the  uterus  does  not  expel  the  dead  ovum,  bacteria 
gain  an  entrance  to  it,  and  a  sapremia,  perhaps  even  a  septicemia, 
follows.  If  the  death  of  the  fetus  is  suspected,  the  woman's  temperature 
and  pulse,  and  her  elimination  should  be  carefully  watched  so  that  the 
first  evidences  of  bacterial  invasion  may  be  noted  and  the  uterus  then 
be  emptied  promptly.  The  difficulty  lies  in  the  fact  that  from  the  fourth 
to  the  fifth  month  it  may  be  very  hard  to  determine  positively  whether 
the  fetus  is  alive  or  dead.  Hence,  in  case  of  any  doubt,  and  in  the 
absence  of  any  signs  of  bacterial  invasion,  it  is  usually  wise  to  wait  and 
see  if  nature  will  not  either  demonstrate  that  the  fetus  is  alive,  or  expel 
it  if  dead.  In  the  meantime  the  obstetrician  should  be  constantly  on 
the  alert  for  any  evidences  of  infection. 

Induction  of  abortion  save  in  emergencies  should  not  he  resorted  to  with- 
out the  advice  and  support  of  a  medical  colleague. 

Methods  of  Induction  of  Abortion. — IMany  methods  have  been  ad- 
vocated, tried  and  abandoned  as  dangerous,  too  slow  or  ineffectual. 
Among  these  may  be  mentioned  the  use  of  drugs,  as  ergot,  rue,  savine, 
parsley,  tansy,  pennyroyal,  etc.  Pituitary  extract,  lately  introduced, 
has  also  been  found  unsuitable  for  this  purpose.  The  use  of  electricity, 
tamponade  of  the  vagina,  and  the  use  of  cervical  tents  are  other  examples 
of  ob.solete  methods. 


INDUCTION  OF  ABORTION  735 

The  two  methods  which  at  the  present  day  may  be  regarded  as  the 
best  are : 

1.  A  mechanical  dilatation  of  the  cervix  with  a  glove-stretcher  dilator, 
followed  at  the  same  sitting  with  a  cleaning  out  of  the  uterus  with 
curette,  ovum  forceps  (for  this  purpose  there  is  nothing  better  than  the 
looped  sponge-holder)  and  a  double-current  catheter.  The  value  of  the 
use  of  the  gloved  finger  in  the  cavity  of  the  uterus  to  determine  that  it 
is  empty  has  already  been  mentioned  (see  page  518). 

2.  The  same  method  as  the  abo\-e  preceded  by  a  preparatory  softening 
and  dilatation  of  the  cervix  by  tamponade  of  the  cervical  canal  and  the 
vagina  with  gauze. 

The  choice  between  the  two  methods  depends  upon  the  duration  of 
the  pregnancy  and  the  softness  and  dilatability  of  the  cervix. 

During  the  first  two  months  of  pregnancy,  while  the  uterus  and  the 
ovum  are  small,  the  first  method  by  which  the  uterus  is  emptied  at  a 
single  sitting  is  the  method  of  choice.  After  the  second  month,  unless 
the  cervix  is  unusually  soft  and  dilatable,  the  second  method  with  its 
preparatory  softening  and  dilatation  of  the  cervix  is  to  be  recommended. 

Technic. — In  the  first  method  the  technic  is  largely  that  of  an 
ordinary  curettage  and  requires  the  same  preparation  of  instruments, 
hands  and  field  of  operation,  with  sterile  draping  of  the  vulva,  thighs, 
etc.  There  are,  however,  certain  dift'erences  between  this  operation  and 
an  ordinary  curettage,  depending  on  the  fact  that  the  patient  is  pregnant 
and  the  uterine  wall  is  softer  and  more  easily  penetrated  than  in  the 
non-pregnant  state.  For  this  reason  it  is  extremely  important  that  little 
force  be  used  in  all  intra-uterme  manipulations  and  for  most  of  the  work 
a  stiff,  blunt  curette  should  be  used  rather  than  a  sharp  one,  and  what 
little  pressure  is  employed  in  the  use  of  the  instrument  should  be 
employed  in  coming  toward  the  operator  rather  than  in  going  from  him. 
The  author  does  not  think  it  necessary  that  the  careful  man  should 
make  the  rule  never  to  use  a  sharp  curette  in  this  operation,  as  often, 
after  he  has  supposedly  cleaned  out  the  uterus  with  his  blunt  curette, 
he  is  in  the  habit  of  very  gently  going  over  the  uterine  cavity  wdth  a 
sharp  curette  to  loosen  any  decidua  which  may  have  escaped  the  blunt 
instrument.  If  it  is  possible  to  introduce  one  or  two  fingers  into  the 
uterine  cavity,  it  is  of  the  greatest  advantage  to  do  so,  as  by  depressing, 
with  the  hand  on  the  abdomen,  one  part  of  the  uterus  after  another 
toward  the  finger  within  it,  all  parts  of  the  uterine  cavity  may  be  explored 
and  any  foreign  substance  detected.  After  irrigating  the  uterine  cavity 
with  saline  solution  in  order  to  wash  out  all  loosened  debris,  it  is  well 
to  pack  the  uterus  and  vagina  with  gauze,  either  a  bismuth  gauze  or  a 
weak  iodoform  gauze,  which  will  remain  sweet  longer  than  plain  gauze, 
and  leave  it  for  twenty-four  hours.  The  advantage  of  the  gauze  tam- 
ponade is  that  it  not  only  prevents  excessive  bleeding,  but  on  its  with- 
drawal on  the  following  day  it  wipes  off  from  the  inner  surface  of  the 
uterine  wall  any  secundines  which  may  have  escaped  the  curette  on  the 
day  before. 

In  the  second  method  the  procedure  is  carried  out  in  two  sittings. 


736        IXDUCTIOX  OF  ABORTION  AND  PREMATURE  LABOR 

At  the  first  sitting,  with  sterile  hands,  instruments  and  field  of  operation, 
a  speculum  is  introduced,  the  cervix  is  seized  with  a  bullet  forceps  or 
a  volsella,  steadied  and  dilated.  The  cervical  canal  and  the  vagina  are 
then  firmly  packed  with  bismuth  or  weak  iodoform  gauze  and  left  for 
about  twenty-four  hours.  At  the  end  of  that  time  the  cervix,  which  at 
the  first  sitting  was  found  long  and  rigid,  will  often  be  found  softened, 
shortened  and  easily  dilatable.  In  fact  the  operation  of  emptying  the 
uterus,  which  the  day  before  would  have  been  very  difficult,  is  often 
found  a  very  easy  one,  the  cervix  readily  admitting  one  or  more  fingers 
and  either  with  or  without  the  use  of  the  curette  and  sponge-holder,  easily 
allowing  rapid  emptying  of  the  uterus.  In  this  second  method,  as  in  the 
first,  after  irrigating  the  uterus,  preferably  with  hot  sterile  salt  solution, 
it  is  desirable  to  pack  the  uterus  and  vagina  with  bismuth  or  weak 
iodoform  gauze,  not  only  for  controlling  hemorrhage,  but  for  wiping  out 
the  cavitv  of  the  uterus  when  withdrawing  the  gauze. 


INDUCTION    OF   PREMATURE  LABOR. 

General  Indications. — "When  the  continuance  of  the  gestation  to  full 
term  would  expose  either  mother  or  child  to  serious  danger  which  might 
be  diminished  or  avoided  by  the  arrest  of  the  pregnancy  at  any  time  after 
the  period  of  viability  of  the  child,  the  induction  of  premature  labor  is 
indicated.  The  indications  for  the  induction  of  premature  labor  may 
be  either  fetal  or  maternal. 

Fetal  Indications. — The  indications  arising  from  the  fetus  may  usually 
be  placed  in  one  of  the  three  following  groups: 

1.  Habitual  oversize  or  premature  ossification  of  the  fetal  skull. 

2.  Habitual  death  of  the  fetus  during  the  last  days  or  weeks  of 
pregnancy. 

3.  Fetal  death. 

A  glance  at  the  above  group  demonstrates  at  once  that  with  the 
exception  of  the  last,  the  fetal  indications  for  induction  of  premature 
labor  are  more  apt  to  be  recognized  in  subsequent  pregnancies  rather 
than  in  the  first.  Occasionally,  when  a  large  man,  as  a  member  of  a  foot- 
ball squad,  or  of  a  crew,  marries  a  very  petite  young  lady,  a  child  too 
large  for  her  pelvis  is  suspected  and  careful  observation  with  pelvimetry 
and  cephalometry  practised  throughout  the  latter  half  of  the  pregnancy 
confirms  this  suspicion,  and  recognizes  the  indication  for  premature 
labor.  As  a  rule,  however,  it  is  the  history  of  previous  dystocia  with 
subsequent  fetal  findings  that  determines  the  fetal  indication  for  inter- 
ruption of  the  pregnancy. 

Occasionally,  for  reasons  difficult  to  state,  probably  in  most  cases  an 
obscure  toxemia,  the  fetus  suddenly  dies  in  utero  a  week  or  two  before 
term.  In  one  of  the  author's  cases  this  occurred  twice  at  about  the  same 
period  of  pregnancy:  two  weeks  before  term.  In  these  cases  induction 
of  premature  labor  a  little  prior  to  the  time  at  which  the  fetus  has  died 
in  previous  pregnancies  is  distinctly  indicated.     In  the  author's  case 


INDUCTION  OF  PREMATURE  LABOR  737 

just  referred  to,  induction  of  labor  three  weeks  ahead  of  term  in  the 
third  pregnancy  succeeded  in  obtaining  a  living  child. 

As  in  the  case  of  a  dead  fetus  in  the  early  months,  so  in  the  latter 
months  of  pregnancy.  The  presence  of  the  dead  fetus  usually  stimu- 
lates the  uterus  to  contract  and  expel  it.  In  a  few  cases  in  which  the 
death  and  retention  of  the  fetus  has  been  determined  and  the  mother's 
health  seems  to  be  affected  by  it,  induction  of  premature  labor  is  indicated. 

Maternal  Indications. — The  indications  arising  from  the  mother  may 
relate  to  her  'parturient  canal,  the  placenta,  or  her  general  system. 

Parturient  Canal. — One  of  the  common  indications  for  induction  of 
premature  labor  is  a  contracted  pelvis  and  consequently  narrowed 
parturient  canal.  The  diameter  of  the  fetal  skull  most  likely  to  cause 
difficulty  in  delivery  is  the  biparietal.  According  to  the  investigations 
of  Budin,  Tarnier  and  others,  this  diameter  which  at  term  averages 
9.25  cm.,  at  eight  months  averages  8.25  cm.,  and  at  seven  months,  7  cm. 
These  facts  make  rational  the  induction  of  premature  labor  in  con- 
tracted pelves  and  indicate  approximately  the  amount  of  prematurity 
needed  for  different  degrees  of  contraction.  In  general,  it  may  be 
stated  that  in  the  interests  of  the  child  it  is  desirable  to  have  the  preg- 
nancy approach  as  near  term  as  possible  without  subjecting  either  child 
or  the  mother  to  too  much  trauma  in  the  delivery.  As  a  fetus  under 
eight  months  has  little  vitality  to  withstand  trauma  in  delivery,  it  is 
seldom  desirable  to  induce  a  labor  for  contracted  pelvis  under  eight 
months  of  gestation  and,  indeed,  eight  months  and  a  week  are  much  to 
be  preferred. 

The  Placenta. — ^The  indications  for  induction  of  premature  labor  in 
placenta  previa  and  in  accidental  hemorrhage  will  be  found  discussed 
under  these  headings.  It  may  be  stated  here  that  while  the  indications 
vary  with  the  variety  of  these  complications,  it  is  well  established  that 
in  complete  placenta  previa  and  in  a  complete  separation  of  a  normally 
situated  placenta — "accidental  hemorrhage" — induction  of  premature 
labor  is  indicated. 

Conditions  of  the  General  System. — As  in  the  early  months  of  preg- 
nancy, prior  to  the  viability  of  the  child,  certain  grave  systemic  affec- 
tions indicate  induction  of  abortion,  so  in  the  later  months  do  they 
indicate  induction  of  premature  labor.  Moreover,  here  as  in  the  early 
months  toxemia  stands  foremost  in  the  frequency  of  its  occurrence  as  an 
indication  for  induction  of  premature  labor.  The  form  of  toxemia  most 
often  seen  in  the  later  months  is  that  threatening  eclampsia  rather  than 
pernicious  vomiting,  although  either  the  liver  or  the  kidney  may  be  the 
organ  chiefly  involved.  It  must  be  borne  in  mind  also  that  if  the  mother 
is  toxic  the  child  may  be  poisoned  by  remaining  in  the  uterus  and  be 
exposed  to  greater  danger  by  a  continuation  of  the  pregnancy  than  by 
its  interruption.  This  is  evidenced  by  the  frequent  occurrence  of  fetal 
death  due  to  the  toxemia  of  the  mother  prior  to  the  onset  of  labor. 

Advanced  cardiac  disease  may  indicate  induction  of  premature  labor 
in  the  hope  that  the  labor  will  be  easier  if  the  child  is  smaller,  and  con- 
sequently less  strain  will  be  thrown  upon  the  overtaxed  heart.  More- 
47 


738        INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR 

over,  there  is  always  the  hope  that  with  the  pregnancy  over,  the  heart 
will  resume  its  compensation. 

Various  other  constitutional  affections,  as  of  the  nervous  system, 
blood,  etc.,  which  are  aggravated  by  the  pregnancy  and  give  hope  of 
marked  improvement  after  the  pregnancy  is  terminated,  justify  induc- 
tion of  premature  labor  as  soon  as  the  fetus  has  reached  a  period  when 
there  is  every  prospect  that  it  will  sur^'ive  if  brought  into  the  world. 

Prognosis. — The  prognosis  for  the  mother  depends  largely  upon  the 
indication  for  the  operation.  If  the  indication  is  a  contracted  parturient 
canal,  the  prognosis  for  the  mother  under  the  modern  aseptic  methods 
is  good.  If,  however,  the  indication  for  the  interruption  of  the  pregnancy 
is  some  grave,  systemic  disease,  the  maternal  prognosis  depends  largely 
upon  her  general  condition. 

The  prognosis  for  the  child  depends  largely  upon  its  weight  and  devel- 
opment and  whether  or  not  it  is  suffering  from  a  toxemia  resulting  from 
the  same  condition  in  the  mother.    Two  facts  are  worthy  of  mention : 

1 ,  It  is  the  maturity  of  the  child  rather  than  its  size  and  weight  which 
determines  its  resistance. 

2.  A  toxic  baby  has  much  less  resistance  than  one  which  is  not  toxic- 
There  is  absolutely  no  foundation  for  the  wide-spread  belief  that  a 

se^'en  months'  fetus  has  more  chance  of  survival  than  one  at  eight  months. 
Of  course  the  nearer  to  term  the  pregnancy  reaches,  other  things  being 
equal  and  the  mother  not  toxic,  the  better  the  chance  of  survival  of  the 
fetus. 

Methods  of  Inducing  Premature  Labor. — The  use  of  various  drugs 
for  induction  of  premature  labor,  as  for  induction  of  abortion,  has  been 
found  either  inefficient  or  unsafe,  and  are  of  interest  simply  as  matter 
of  ancient  history.  The  use  of  castor  oil  which  in  full  doses  will  sometimes 
incite  labor  if  the  woman  is  at  term,  is  practically  of  no  value  in  inducing 
premature  labor. 

The  intra-uterine  injection  of  from  one  to  two  ounces  of  sterilized 
glycerin  between  the  membranes  and  the  uterine  wall  was  suggested 
by  Pelzer,  of  Germany,  as  a  means  of  induction  of  premature  labor,  and 
several  years  ago  was  quite  extensively  tried  in  this  country.  Pelzer 
explained  its  action  in  three  ways: 

1 .  By  mechanical  separation  of  the  membranes. 

2.  By  direct  irritation  of  the  uterine  mucosa  as  of  the  rectal  mucosa 
when  used  in  an  enema  or  suppository, 

3.  By  the  affinity  of  glycerin  for  water,  some  of  the  liquor  amnii 
was  drawn  through  the  membranes  with  more  or  less  collapse  of  the 
amniotic  sac. 

Very  soon  after  the  introduction  of  this  method  of  Pelzer,  cases  began 
to  be  reported  in  which  renal  irritation  with  hematuria,  albuminuria, 
etc.,  followed  the  intra-uterine  injection  of  glycerin,  and  on  account  of 
this  danger  and  the  danger  of  injecting  air  into  the  uterine  sinuses  the 
method  rapidly  fell  into  disuse. 

There  are  four  methods  of  induction  of  premature  labor  which  at 
the  present  time  deserve  consideration : 


INDUCTION  OF  PREMATURE  LABOR 


739 


1.  Dilatation  of  the  cervix  with  an  elastic  bag. 

2.  The  intra-uterine  introduction  of  a  bougie — the  Kraiise  method. 

3.  The  tamponade  of  the  vagina. 

4.  Puncture  of  the  membranes. 

Of  these  four  methods  the  last  two  are  employed  simply  as  adjuvants 
of  the  first  two. 

Dilatation  of  the  Cervix  with  an  Elastic  Bag. — This  is  the  author's 
choice  among  the  methods  just  mentioned  and  is  the  method  generally 


Fig.  432. — Voorhees's  modification  of,  Champetier  de  Ribes's  bags. 


employed  at  the  Sloane  Hospital.  It  has  the  great  advantage  over 
the  second  method  in  that  it  does  not  usually  rupture  the  membranes 
and  follows  nature's  plan  of  dilating  the  cervix  by  elastic  pressure.  Its 
presence  in  the  cervical  canal  stimulates  uterine  contractions  and  the 
conical  shape  of  the  bag  furnishes  a  fluid  wedge  which  imitates  nature's 
method. 

The  bags  used  by  the  author  are  those  of  Champetier  de  Ribes  as 
modified  by  Dr.  James  D.  Voorhees,  of  New  York.  They  are  of  four 
sizes,,  as  shown  in  Fig.  432. 


r40 


INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR 


Except  in  cases  with  a  long,  rigid  cervix,  it  usually  is  unnecessary  to 
use  bag  No.  1,  as  No.  2  can  be  introduced  at  the  first  sitting,  some- 
times even  No.  3.  As  the  largest  size,  bag  No.  4,  sometimes  displaces 
the  presenting  part,  allowing  the  possibility  of  a  prolapse  of  the  cord, 
the  author  floes  not  use  bag  No.  4  unless  the  presentation  is  either  a 
breech  or  a  l)reech  presentation  is  desired,  as  in  a  placenta  previa. 

In  the  introduction  of  the  bags  the  vulva  should  be  cleansed  and 
draped  as  for  any  operative  delivery.    Unless  the  patient  is  nervous  and 


Fig.  433 


Fig.  434 


Figs.  433  and  434. — Looped  sponge-holder. 


apprehensive,  or  the  cervical  canal  very  small,  no  anesthetic  is  required. 
The  introduction  of  the  bag  is  facilitated  by  the  lubricating  effect  of  a 
lysol  vaginal  douche,  0.5  per  cent.,  although  this  is  not  a  necessity. 

The  instruments  required  for  this  operation  are  a  forceps  for  holding 
and  introducing  the  bag  after  it  has  been  folded  up;  for  this  a  looped 
sponge-holder  answers  nicely  (see  Figs.  433  and  434) .  A  syringe  for  distend- 
ing the  bag  after  it  is  in  place,  and  here  may  be  used  eitlier  a  metal  piston 
syringe,  or  a  soft-ru})ber  bulb  syringe  (see  Figs.  435  and  430),  (in  i)rivate 
practice  the  latter  is  easier  to  carry  in  the  obstetrical  bag  and  answers 


INDUCTION  OF  PREMATURE  LABOR 


741 


nicely) ;  an  artery  clamp  to  compress  the  end  of  the  tuhe  after  the  bag  is 
filled,  and  a  pair  of  scissors  to  cut  the  tape  with  which  the  end  of  the  tube 
is  tied,  so  as  to  remove  the  clamp. 

If  the  cervical  canal  is  very  small  and  rigid  it  may  be  necessary  to 
dilate  the  cervix  with  a  glove-stretcher  dilator,  as  a  preliminary  step  to 
the  introduction  of  the  bag.  In  such  a  case  an  anesthetic  should  be 
employed.  In  private  practice  with  only  one  assistant,  and  she  the 
nurse,"^it  is  well  to  have  the  patient  lying  across  the  bed  with  douche  pan 
under  her  hips  and  knees  elevated.    The  advantage  of  the  douche  pan 


Fig.  435 


Fig.  436 


Fig.  435  and  436. — Syringes  used  for  distending  elastic  bags. 


is  that  it  not  only  allows  the  operator  to  cleanse  the  vulva,  and  if  desired 
give  a  vaginal  douche,  but  elevates  the  hips  and  facilitates  manipula- 
tions. In  a  hospital  the  natural  position  would  be  on  the  table  in  the 
lithotomy  position  and  with  a  Kelly  pad  under  her  hips.  The  vulva 
should  be  surrounded  with  sterile  towels. 

Having  folded  the  bag  into  as  small  a  compass  as  possible,  it  is  seized 
with  forceps  (see  Fig.  437)  and  with  the  two  fingers  of  the  left  hand  in 
the  vagina  to  depress  the  perineum  and  serve  as  a  guide,  the  forceps 
containing  the  bag  is  passed  by  the  right  hand  along  the  vaginal  fingers 
into  the  cervix  until  the  bag  passes  the  internal  os.     The  forceps  is 


742        INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR 

then  withdrawn,  the  syringe  adjusted  to  the  tube  of  the  bag  whieh  is 
outside  the  vulva  and  the  l)ag  is  distended  with  some  sterile  fluid;  prefer- 
ably 0.5  per  cent,  lysol  solution,  while  the  vaginal  fingers  are  kept  in  posi- 
tion, to  make  sure  that  the  bag  does  not  slip  from  the  cervix  while  being 
filled.  The  tube  is  then  clamped  with  an  artery  clamp  just  above  the 
nozzle  of  the  syringe  and  the  syringe  withdrawn.  The  tube  is  tied  with 
narrow  tape  above  the  clamp;  the  clamp  withdrawn;  the  tube  folded 
upon  itself  and  placed  in  the  vagina  and  a  sterile  dressing  applied  to  the 


Fig.  437. — Bag  in  grasp  of  forceps. 


Fig.  438.— Distended  bag. 


vulva.  The  appearance  of  the  distended  bag  is  shown  in  Fig.  438.  As 
a  rule  the  labor  pains  start  in  from  two  to  four  hours  after  the  introduc- 
tion of  the  bag.  Some  uteri,  however,  seem  very  insensitive  to  mechan- 
ical stimuli  and  occasionally  a  bag  will  remain  within  the  cervical  canal 
for  twenty-four  hours  w^ith  scarcely  any  uterine  contractions  resulting. 
This  does  not  mean,  however,  that  nothing  has  been  accomplished,  as 
the  presence  of  the  bag  usually  softens  and  to  a  certain  extent  dilates 
the  cervix  even  without  evident  uterine  contractions,  so  that  at  the  end 
of  twenty-four  hours  the  bag  can  be  withdrawn  and  the  next  size  larger 


INDUCTION  OF  PREMATURE  LABOR  743 

introduced.  The  rule  is  that  when  bag  No.  3  has  been  expelled  or  with- 
drawn labor  is  sufficiently  under  way  to  need  no  further  stimulation. 
Occasionally,  however,  further  stimulation  is  needed,  as  will  be  referred 
to  when  discussing  the  second  method  of  induction  of  premature  labor. 

The  Introduction  of  a  Bougie. —  The  Krause  Method. — Until  recent  years 
the  method  most  generally  employed  for  induction  of  labor  was  the 
introduction  of  a  catheter  or  bougie  between  the  membranes  and  the 
uterine  wall.  The  bougie  without  an  eye  near  the  tip  is  much  better 
than  a  catheter  with  the  eye,  as  with  the  latter  there  is  a  direct  channel 
for  air  and  bacteria  from  without  to  the  cavity  of  the  uterus. 

If  the  bougie  is  sterile  and  with  sterile  hands  is  introduced  with  all 
aseptic  precautions,  there  is  little  maternal  risk  in  this  method,  but  it 
is  open  to  one  great  objection.  It  is  very  apt  to  cause  a  rupture  of  the 
membranes  with  the  first  few  uterine  contractions  and  with  the  draining 
away  of  the  liquor  amnii  there  results  a  dry  labor  with  greater  direct 
pressure  upon  the  fetus,  greater  delay  in  the  dilatation  of  the  cervix, 
and  the  usual  disadvantage  of  a  dry  labor.  Furthermore,  in  some  cases 
the  presence  of  the  bougie  for  twenty-four  to  thirty-six  hours  fails  to 
excite  uterine  contractions.  For  these  reasons  the  author  prefers  not  to 
use  a  bougie  as  the  initial  means  of  inducing  labor,  but  to  reserve  its  use 
for  cases  in  which  after  bag  No.  3  has  been  used  and  has  been  expelled 
or  withdrawn,  uterine  contractions  have  ceased  and  further  uterine 
stimulation  is  needed.  With  a  cervix  sufficiently  dilated  to  allow  bag  No. 
3  to  pass,  even  if  the  membranes  do  rupture  from  the  presence  of  the 
bougie,  it  will  do  little  harm.  From  the  descent  of  the  presenting  part 
it  may  still  further  aid  the  bougie  in  stimulating  uterine  contractions 
and  thus  aid  the  labor. 

Technic. — The  bougie  (see  Fig.  439)  should  be  of  the  so-called  gum- 
elastic  variety,  and  of  a  size  a  little  smaller  than  a  common  lead-pencil. 
As  the  bougie  sometimes  bends  on  introduction  it  is  always  well  to  have 
on  hand  a  sterilized  stilet  with  which  to  maintain  its  shape  if  necessar}'^ 
(see  Fig.  440).  With  hands  covered  with  sterile  gloves  and  vulva  and 
vagina  prepared  for  operation,  two  fingers  of  the  left  hand  are  passed 
along  the  vagina  to  the  cervix.  The  sterilized  bougie,  with  or  without 
its  stilet,  held  in  the  right  hand,  is  then  passed  along  the  fingers  of  the 
left  hand  to  and  within  the  cervix,  thence  gently  inserted  as  near  the 
fundus  as  it  will  go  without  the  use  of  force,  letting  it  take  the  path  of 
least  resistance.  After  the  bougie  has  been  introduced,  it  is  well  to  pack 
the  vagina  with  bismuth  or  weak  iodoform  gauze,  not  only  to  hold  the 
bougie  in  place,  but  to  gain  whatever  uterine  stimulation  may  arise 
from  vaginal  tamponade.  If  at  the  end  of  twenty^our  hours  uterine 
contractions  have  not  started,,  it  is  usually  wise  to  withdraw  the  gauze 
and  the  bougie  and  either  insert  another  bougie  or  an  elastic  bag. 

Tamponade  of  the  Vagina. — Occasionally  the  tamponade  of  the  vagina 
with  gauze  will  bring  on  uterine  contractions.  This  is  more  apt  to  be 
true  in  the  early  months  of  pregnancy,  especially  if  the  cervical  canal  as 
well  as  the  vagina  is  tamponed.  In  times  past  this  tamponade  of  the 
vagina  has  been  recommended  as  a  means  of  inducing  labor.    Its  uncer- 


744         INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR 

taiiity  in  time  aiul  effectiveness,  however,  has  been  so  great  that  at  the 
present  day  it  is  never  used  b\'  itself  for  this  purpose,  but  is  often  used 
as  an  adjuvant,  as  after  the  intnxhiction  of  a  bougie  where  as  alread}' 
indicated,  it  serves  a  double  purj)ose  of  holding  in  the  bougie  and  stinui- 
lating  uterine  contractions. 

Puncture  of  the  Membranes. — It  has  to  be  admitted  that  puncture  of 
the  membranes  with  draining  away  of  the  liquor  amnii  is  usually  followed 
after  a  longer  or  shorter  interval  by  uterine  contractions  and  beginning 
labor.   It  is  not  a  method  to  be  recommended  for  induction  of  premature 


^ 


Fig.  439.— Bougie.       Fig.  440.— Stilet. 


labor  under  ordinary  circumstances,  as  it  is  very  uncertain  in  time,  and 
results  in  a  dry  labor  Mith  all  its  disadvantages  and  dangers.  As  an 
adjuvant  to  other  methods,  howe^•er,  it  is  often  of  marked  value.  Thus, 
when  the  cervix  has  been  sufficiently  dilated  to  allow  a  No.  3  Voorhees 
bag  to  pass,  the  puncture  of  the  membranes  may  start  afresh  uterine 
contractions  which  were  becoming  less  and  less.  Furthermore,  in  a 
placenta  previa  of  the  lateral  type  with  a  vertex  presentation  and  with 
the  woman  bleeding,  a  puncture  of  the  membranes  will  often  allow  the 
head  to  descend  and  control  the  bleeding  by  pressure  as  well  as  stimulate 
uterine  contractions  and  the  progress  of  the  labor. 


CHAPTER  XXV. 
FORCEPS.  - 

Historical  Sketch. — The  obstetric  forceps  has  been  of  such  service  in 
the  cause  of  humanity  that  a  brief  review  of  the  history  of  the  instru- 
ment is  both  interesting  and  instructive.  ^ 

Probably  the  first  mention  of  the  use  of  the  forceps  for  the  dehvery  of 
a  hving  child  is  found  in  the  writings  of  Avicenna,  an  Arabian  physician, 
who  was  born  a.d.  980,  and  died  a.d.  1037.  His  writings  passed  through 
several  translations  into  Latin,  the  common  language  of  science  at  that 
time,  the  translation  by  Benedictus  Rinius,  of  Venice,  being  published  in 
1555.^  In  this  translation  there  is  one  chapter  describing  the  delivery 
of  a  living  child  by  means  of  the  forceps  and  another  chapter  giving 
directions  for  the  extraction  of  a  dead  child. 

Subsequent  writers  also  mention  the  use  of  the  forceps,  but  just  who 
first  devised  the  instrument  has  never  been  thoroughly  established. 

Jacobus  Ruoif,  a  native  of  Zurich,  published,  in  1524,  a  treatise  on 
obstetrics,  in  which  he  described  a  long  and  a  short  forceps,  which  he 
had  invented,  stating  that  his  instrument  had  no  teeth  on  it  and  that 
the  child  could  easily  be  delivered  by  his  forceps  if  it  could  be  applied 
to  the  head.  The  forceps  of  these  early  writers  were  crude  instruments 
with  blades  not  separable,  and  therefore  could  only  be  introduced  together 
and  then  adjusted  to  the  head.  From  the  middle  of  the  sixteenth  to  the 
middle  of  the  seventeenth  century  but  little  progress  was  made  either 
in  the  construction  or  use  of  the  forceps.  This  brings  the  history  to  the 
Chamberlen  family,  whose  different  members  so  improved  the  construc- 
tion of  the  instrument  and  so  perfected  its  use  that  by  many  writers  the 
invention  of  the  forceps  has  been  incorrectly  credited  to  them. 

This  famous  family  was  originally  resident  in  Paris.  The  founder  of 
the  English  branch  of  the  family  was  William  Chamberlen,  probably 
a  surgeon,  who  being  obliged  to  leave  Paris  on  account  of  his  religious 
beliefs,  went  to  England  in  1569. 

William  Chamberlen  was  evidently  fond  of  the  name  "Peter,"  for 
having  two  sons  he  called  them  both  by  that  name.  Both  of  these  sons, 
Peter  the  elder  and  Peter  the  younger,  practised  medicine  in  London 
and  became  successful,  especially  in  midwifery.  Peter  the  elder  died  in 
1631,  and  Peter  the  younger  in  1626,  leaving  a  son  also  named  Peter  who 
was  called  Doctor  Peter,  to  distinguish  him  from  his  father  and  from 
his  uncle.  Doctor  Peter  was  the  first  member  of  the  family  to  obtain 
the  degree  of  M.D.,  receiving  it  from  Padua  in   1619,  and  later  from 

1  Avicennge,  Liber  Canonis  de  Medicinis  Cordial  ibus  et  Canticala  Benedicto  Rinio  Veneto- 
Venetiis,  1555,  liber  III,  fen.  xxl,  tract  11,  cap.  26,  p.  390. 

(745  J 


746 


FORCEPS 


Oxford  and  Cambridge.^  He  had  a  large  obstetric  practice  and  died  in 
1683  at  Woodham,  ]\Iortimer  Plall,  in  Essex,  leaving  several  sons,  one 
of  whom  named  Hugh,  was  destined  to  play  a  prominent  part  historically 
in  spreading  the  knowledge  of  the  obstetric  forceps. 

Hugh  Chamberlen  was  born  in  1630.  He  was  an  accoucheur  and  a 
man  of  considerable  ability,  although  it  is  doubtful  whether  he  ever 
obtained  the  degree  of  M.D.  In  1670  he  visited  Paris  and  became 
acquainted  with  the  famous  obstetrician  Mauriceau,  to  whom  he  tried 
to  sell  the  family  secret,  claiming  that  by  it  he  could  deliver  the  most 
difficult  case  in  a  few  moments.  As  a  test  case  Mauriceau  gave  him  a 
rhachitic  dwarf.  After  three  hours  of  vigorous  effort  he  was  obliged  to 
acknowledge  his  failure  and  the  woman  died  undelivered  twenty-four 
hours  later  with  uterus  badly  lacerated.  Chamberlen  returned  to  Eng- 
land and  lived  there  several  years,  but  either  on  account  of  his  unpopular 
political  views  or  certain  financial  difficulties,  he  was  obliged  to  leave 


Fig.  441. — Chamberlen  forceps. 


England  and  moved  to  Amsterdam,  where  he  spent  the  remainder  of 
his  days. 

While  living  in  Amsterdam  he  sold  his  so-called  family  secret  to  Room- 
huysen,  an  obstetrician,  who  soon  disposed  of  it  to  the  Medico-Phar- 
maceutical College  of  Amsterdam.  This  college  soon  secured  the  sole 
right  to  license  physicians  to  practise  in  Holland  and  would  grant  this 
license  only  to  those  who  would  take  the  course  in  obstetrics,  pay  a 
special  fee,  and  under  pledge  of  secrecy  receive  the  knowledge  of  the 
Chamberlen  instrument.  This  went  on  until  about  the  middle  of  the 
eighteenth  century,  when  it  is  said  two  public-spirited  citizens  of  Hol- 
land, Vischer  and  Van  der  Poll,  disgusted  that  what  was  claimed  to  be 
such  a  boon  to  humanity  should  remain  a  secret,  took  the  medical  course, 
paid  the  fee  for  the  secret  and  published  it.  It  proved  to  be  only  one 
blade  of  the  forceps.    Whether  this  was  all  Hugh  Chamberlen  disposed 

1  Partridge,  History  of  the  Obstetric  Forceps,  Amer.  Jour.  Obst.,  li,  765. 


HISTORICAL  SKETCH 


747 


of,  or  whether  the  college  held  back  part  of  the  secret  is  not  clear.  Any 
doubt  existing  concerning  the  association  of  the  forceps  with  the  Cham- 
berlen  family  was  cleared  up  by  the  finding,  in  1813;  in  a  trunk  in  the  old 
Chamberlen  house  at  Essex,  formerly  occupied  by  Doctor  Peter,  four 
pairs  of  forceps  (see  Fig.  441)  which  had  evidently  been  used  by  different 
members  of  the  Chamberlen  family  and  which  represented  different 
stages  of  development  in  the  instrument.  They  difi^ered  from  the  forceps 
previously  described  by  Ruoff  by  having  separate  blades. 


Fig.  442 


Fig.  443 


Figs.  442  and  443. — Chamberlen  forceps. 


The  differences  in  the  shape  of  the  blades  showed  progressive  improve- 
ment and  the  fact  that  the  lock  had  been  found  insufficient  is  evidenced 
by  the  reinforcement  by  wrapping  as  shown  in  the  middle  two  pairs. 
All  the  forceps  were  short  forceps  with  only  a  cephalic  curve  and  therefore 
adapted  only  to  low  work.  The  lateral  and  anteroposterior  view  of  the 
perfected  Chamberlen  forceps  is  shown  in  Figs.  442  and  443.  The  credit 
of  introducing  the  forceps  into  general  use  in  England  belongs  to  William 
Giffard,    whose    book   entitled    Cases   in   Midwifery,   published    by  a 


748 


FORCEPS 


friend  in  1734,  shortly  after  his  death,  contained  a  description  of  225 
cases  seen  by  him  durinof  the  years  of  1724-1731,  in  many  of  wliich 
he  used  the  forceps.  The  l)()()k  also  contains  an  ilhistration  of  Ins 
instrument. 

The  next  marked  improvement  in  the  obstetric  forceps  appeared  about 
the  middle  of  the  eighteenth  century,  when  Levret,  in  France  in  1747, 
and  Smellie  in  England  in  1751,  working  independently  of  each  other, 
added  a  pelvic  curve  (as  seen  in  Figs.  444  to  447).    The  Smellie  forceps  is 


Fig.  444 


Fig.  445 


Figs.  444  and  445. — Levret  forceps. 


a  shorter  forceps  than  the  Levret,  has  less  of  a  pelvic  curve  and  by  Smellie 
was  often  covered  with  leather  to  prevent  slipping.  From  these  two 
types  of  forceps,  the  Smellie,  with  the  English  lock  and  the  Ivcvret  with 
the  French  lock,  have  descended  the  long  forceps  of  the  present  day. 

From  the  Smellie  forceps  come  the  Simpson,  the  P^lliot  and  the  Tucker- 
McLane  (see  Figs.  448  to  453) .  From  the  Levret  forceps  comes  the  Hodge 
forceps,  and  it  was  evidently  a  modification  of  the  Levret  forceps  to 
which  Tarnier,  in  1877,  added  the  traction  rods  (see  Figs.  454  and  455) 


HISTORICAL  SKETCH  749 

and  enunciated  the  principle  of  axis  traction  which  has  proved  of  great 
vahie  in  high  forceps  deHvery.  - 

From  the  preceding  historical  description  of  the  forceps  it  is  seen 
that  there  are  three  chief  varieties  of  the  forceps: 

1.  The  short  forceps,  illustrated  by  the  Chamberlen  and  the  Smellie 
forceps. 

2.  The  long  forceps,  illustrated  by  the  Levret,  the  Elliot  and  the 
Tucker-]\IcLane. 

3.  The  axis-traction  forceps,  illustrated  by  the  Tarnier. 

Fig.  446  Fig.  447 


( 

f  > 

\ 

Figs.  446  and  447. — Smellie  forceps. 

It  will  be  noted  that  there  are  two  varieties  of  lock,  the  English  lock, 
in  which  one  blade  fits  over  and  into  the  other,  as  seen  in  the  Smellie, 
the  Simpson,  the  Elliot  and  the  Tucker-McLane,  and  the  French  lock, 
in  which  the  blades  are  held  together  by  a  thumb-screw,  as  is  seen  in  the 
Levret  forceps  and  in  the  axis-traction  instrument  of  Tarnier. 

Comparison  of  the  different  instruments  also  shows  two  varieties  of 
blade:   the  fenestrated  blade,  as  seen  in  the  Levret,  the  Tarnier  and 


750  FORCEPS 

the  Elliot  forceps  and  the  solid  blade,  as  seen  in  tlie  Sniellie  and  the 
Tucker-McLane. 

The  relative  value  of  the  fenestrated  and  solid  blade  will  be  discussed 
later. 

The  Function  of  the  Forceps. — The  chief  functions  of  the  obstetric 
forceps  are  two:  (1)  As  a  tractor.  (2)  As  a  rotator.  While  it  is  well 
recognized  that  other  subsidiary  actions  are,  or  may  be,  associated  with 

Fig.  448  Fig.  449 


Figs.  448  ami  449. — .Simpsoa  forceps. 

the  use  of  the  forceps,  such  as  compression,  leverage  and  uterine  stimnla- 
tion,  it  is  u.sually  traction  and  occasionally  rotation  which  are  the  functions 
sought. 

Some  compression  is  inevitably  associated  with  every  forceps  delivery, 
but  it  occurs  because  it  is  unavoidable  in  drawing  a  head  through  a 
canal  which  has  to  dilate  from  within  outward  rather  than  because  com- 
pression is  desired.  A  slight  amount  of  leverage  from  side  to  side  is 
sometimes  employed  in  very  difficult  deliveries,  but  is  much  less  employed 
than  formerly  and  is  seldom  to  be  advised.     While  e^•erv  obstetrician 


CHOICE  OF  A  FORCEPS 


751 


realizes  that  traction  upon  the  forceps  almost  always  stimulates  uterine 
contraction,  no  one  thinks  of  using  the  instrument  solely  for  that  purpose. 

While  formerly  the  use  of  the  forceps  as  a  rotator  was  decried  as  too 
dangerous,  the  skilled  obstetrician  of  the  present  day  aims  at  cephalic 
application  of  the  forceps,  and  in  his  delivery  of  the  head  with  the  cephalic 
application  makes  frequent  use  of  the  power  of  rotation. 

Choice  of  a  Forceps. — In  considering  the  choice  of  a  forceps  for  gen- 
eral use  two  facts  at  once  become  evident:    (1)  That  a  so-called  long 


Fig.  450 


Fig.  451 


Figs.  450  and  451. — Elliot  forceps. 


forceps  will  do  all  the  w^ork  of  which  a  short  forceps  is  capable  and  will 
also  do  its  own  work,  and  that  there  is  therefore  no  reason  for  the 
obstetrician  to  add  to  the  weight  of  his  obstetric  bag  by  carrying  a 
short  forceps.  (2)  That  the  axis-traction  forceps  is  a  complicated  instru- 
ment and  rather  cumbersonae  for  simple  forceps  operations.  A  skilled 
obstetrician  can  do  good  work  with  any  of  the  modern  long  forceps  such 
as  the  Simpson,  the  Elliot  or  the  Tucker-McLane  and  in  general  will 
do  his  best  work  with  the  instrument  with  which  he  is  most  familiar. 


ro'i 


FORCEPS 


For  many  years  the  author  used  the  Simpson  forceps  in  his  work  and 
was  satisfied  with  it,  but  as  time  went  on  he  began  to  appreciate  that 
the  shoulder  in  the  shanks  of  the  Simpson  forceps  exposed  the  tissues 
of  the  vulva  to  greater  tension  than  was  necessary  and  often  it  was 
convenient  to  have  a  longer  instrument.  The  two  simple  long  forceps 
which  at  the  present  day  rival  each  other  in  popularity,  are  the  Elliot 
and  the  Tucker-^IcLane,  and  the  rivalry  depends  upon  the  question: 
Shall  the  blade  be  fenestrated  or  solid?    At  the  Sloane  Hospital  and  in 


Fig.  452 


Fig.  453 


Figs.  452  and  453. — Tucker-McLane  forceps. 


his  private  practice  the  author  uses  and  prefers  for  all  ordinary  forceps 
work  the  Tucker-McLane  instrument  with  the  solid  blade  for  the  follow- 
ing reasons:  As  stated  above  the  skilled  obstetrician  of  today  always 
aims  to  apply  the  forceps  blades  to  the  sides  of  the  child's  head,  i.  e., 
a  cephalic  application.  In  order  to  achieve  this  result  it  is  desirable  to 
have  a  blade  which  will  introduce  easily  and  will  slide  around  the  cir- 
cumference of  the  pelvic  canal.  A  solid  blade,  on  account  of  its  lessened 
tendency  to  catch  upon  any  projecting  object,  will  do  this  more  easily 


CHOICE  OF  A   FORCEPS 


753 


than  a  fenestrated  blade.  Furthermore,  the  blade  which  will  slip  off 
easily  when  desired,  is  a  great  advantage,  and  that  the  solid  blade  will 
do  this  more  readily  than  the  fenestrated  is  known  by  everyone  who 
has  used  both.    The  question  is,  Will  the  solid  blade  slip  when  undesired 


Fig.  454. — Tarnier  axis-traction  forceps.     Traction  handle  separated. 

more  readily  than  the  fenestrated?  This  question  has  exceptionally 
to  be  answered  in  the  affirmative.  It  is  an  undeniable  fact  that  a  fenes- 
trated blade  which  has  been  applied  firmly  to  the  head  and  into  the 
fenestra  of  which  the  tissues  of  the  scalp  have  protruded  will  hold  a 
little  more  firmly  than  the  solid  blade  which  presses  evenly  upon  the 


Fig.  455. — Tarnier  axis-traction  forceps.     Traction  handle  attached. 

outer  surface  of  the  scalp.  On  the  other  hand,  if  the  application  of  the 
forceps  is  as  it  should  be,  and  the  relation  between  passage  and  passenger 
is  suitable  for  forceps  delivery,  slipping  of  the  solid  blade  is  an  accident 
of  the  rarest  occurrence.    Furthermore,  the  smooth,  solid  blade.is  a  little 

48 


754  FORCEPS 

less  likely  to  mar  the  features  of  the  child  than  is  the  fenestrated  blade. 
In  certain  cases  of  difficult  forceps  delivery  the  principle  of  axis  traction 
advocated  by  Tarnier  and  best  exemplified  in  his  forceps  (see  Figs.  454 
and  455)  is  extremely  valuable,  and  if  one  is  to  practice  obstetrics  at  all 
extensively  he  should  carry  in  his  obstetric  bag  two  varieties  of  forceps, 
one  long,  plain  forceps,  and  one  axis-traction  forceps.  The  author's 
preference  is  for  a  Tucker-McLane  and  a  Tarnier  forceps,  and  these  are 
the  two  carried  in  his  obstetric  bag. 

With  these  two  instruments  the  obstetrician  is  provided  for  all  cases 
suitable  for  forceps  delivery.  If  for  any  reason  the  delivery  is  extremely 
difficult  and  the  Tucker-McLane  forceps  with  its  solid  blades  show  a 
tendency  to  slip  (a  very  rare  occurrence),  the  Tarnier  instrument  com- 
bines both  the  fenestrated  blade  and  the  traction  rods,  thus  meeting  all 
indications. 

Indications  for  Forceps  Delivery. — Insufficient  Expulsive  Power. — One 
of  the  most  frequent  indications  for  forceps  delivery  is  a  lack  of  expul- 
sive power  either  uterine,  abdominal,  or  both,  to  overcome  the  resistance 
of  the  parturient  canal.  This  resistance  may  come  either  from  a  dispro- 
portion between  passenger  and  passage  or  from  a  malposition  of  the 
presenting  part. 

The  strength  of  the  patient  may  have  been  exhausted  in  dilating  a 
rigid  cervix  during  the  first  stage,  so  that  little  is  left  for  the  second. 
Or,  during  the  second  stage,  strength  which  would  have  sufficed  for  the 
delivery  of  a  normal  position  may  have  been  spent  in  the  vain  endeavor 
to  rotate  an  occipitoposterior. 

Insufficient  Progress. — An  illustration  of  this  is  seen  in  cases  where  in 
the  interest  of  either  mother  or  child  it  is  advisable  to  terminate  the 
labor  speedily,  as  for  instance,  eclampsia  of  the  mother  or  rapidly  failing 
fetal  heart. 

Frequency. — This  varies  largely  with  the  class  of  patients  with  which 
the  obstetrician  has  to  deal.  Occasionally  it  is  said  by  those  practising 
in  the  country  that  they  have  practised  obstetrics  all  their  lives  and 
have  found  it  necessary  to  use  the  forceps  in  only  a  few  cases.  This  can 
only  mean  one  of  two  things,  either  that  the  patients  under  discussion 
were  very  normal  women,  or  that  the  lives  of  many  children  were  lost 
which  might  have  been  saved  by  the  skilful  use  of  the  forceps. 

At  the  Sloane  Hospital,  in  20,000  consecutive  labors,  forceps  delivery 
was  resorted  to  in  2468  cases,  i.  e.,  12.3  per  cent.,  or  approximately  1  to  8. 

In  500  consecutive  cases  in  the  author's  private  practice,  in  New  York 
City,  forceps  delivery  was  resorted  to  113  times,  i.  e.,  22.6  per  cent.,  or 
ap])roximately  1  to  4. 

Contra-indications. — Forceps  delivery  should  be  considered  contra- 
indicated  in  the  following  conditions: 

1.  Where  a  disproportion  between  child  and  parturient  canal  renders 
delivery  per  vias  naturales  mechanically  impossible. 

2.  Where  the  presentation  or  position  makes  delivery  impossible. 

3.  Undilatable  cervix. 

4.  Unruptured  membranes. 


DANGERS  IN  THE  USE  OF  THE  FORCEPS  755 

Some  of  these  contra-indications  may  be  removed  and  then  the  forceps 
be  properly  indicated.  Thus  a  malpresentation  or  position  may  be 
corrected.  An  imdilatable  cervix  may  be  softened  or  rendered  dilatable 
by  the  elastic  bag  or  other  means.  The  membranes  should  always  be 
ruptured  before  the  application  of  the  forceps. 

Dangers  in  the  Use  of  the  Forceps. — These  may  be  either  (a)  maternal 
or  (b)  fetal. 

Maternal  Dangers. — The  maternal  dangers  consist  chiefly  in  (1)  lacera- 
tions, (2)  fractures,  and  (3)  sloughing. 

Lacerations. — Lacerations  of  the  pelvic  floor  will  occasionally  occur 
with  the  best  of  obstetricians,  whether  the  patient  is  delivered  by  nature 
or  by  the  use  of  the  forceps,  and  at  times  this  laceration  is  favored  by 
leaving  the  woman  too  long  in  the  second  stage  of  labor,  until  the  vulva 
has  become  edematous  before  applying  the  forceps;  in  other  words,  by 
the  neglect  of  the  forceps  rather  than  by  the  use  of  the  instrument. 
On  the  other  hand,  there  are  certain  dangers  of  laceration  by  the  forceps 
which  should  be  recognized  and  avoided.  Among  them  may  be  men- 
tioned: (a)  the  sudden  slipping  of  the  instrument  with  consequent 
laceration  of  the  parturient  canal  on  account  of  an  improper  application 
of  the  instrument;  (6)  the  too  rapid  extraction  of  the  head,  w^ithout 
giving  time  for  dilatation  of  the  canal;  (c)  premature  elevation  of  the 
handles  of  the  instrument  as  the  head  approaches  the  pelvic  floor;  thus 
allowing  the  ends  of  the  blades  to  project  beyond  the  head  and  tear  the 
posterior  vaginal  wall,  perhaps  even  into  the  rectum. 

Fractures. — The  time  for  brute  force  in  the  use  of  the  forceps  has 
passed.  The  author  has  had  under  his  care  a  patient  in  whose  previous 
labor,  the  family  physician,  a  large,  powerful  man,  on  finding  that  he 
was  unable  to  deliver  her  with  the  forceps  by  his  own  strength,  called  in 
a  colleague,  who  with  arms  around  his  waist,  pulled  upon  the  attending 
physician  while  he  pulled  upon  the  forceps.  Is  it  any  wonder  that  in 
such  cases  separation  of  the  symphysis  or  fracture  of  the  coccyx  occurs? 
Straining  of  one  or  both  of  the  sacro-iliac  joints  is  also  a  not  unusual 
result  of  such  improper  force. 

In  this  connection  it  may  be  well  to  mention  that  in  certain  cases  in 
which  the  coccyx  has  been  previously  fractured  by  a  fall  and  has  united 
at  an  angle,  a  refracture  may  occur  either  under  the  proper  use  of  the 
forceps  or  even  by  the  unaided  efforts  of  nature.  In  one  of  the  author's 
cases  this  occurred  in  her  first  and  second  confinements,  which  were  for- 
ceps deliveries,  and  in  her  third  confinement,  which  was  otherwise 
normal,  the  coccyx  was  heard  to  snap  under  the  normal  expulsive  powers 
of  nature. 

Sloughing. — Under  the  influence  of  too  long  and  too  powerful  traction 
upon  the  forceps,  especially  if  this  traction  is  not  intermittent,  the  soft 
parts  may  be  so  compressed  against  the  bony  pelvis  as  to  lose  their  vitality 
and  sloughing  occur.  This  was  formerly  the  cause  of  many  of  the  cases 
of  vesicovaginal  fistula.  Since  the  proper  use  of  the  forceps  has  been 
better  understood  and  the  instrument  has  been  used  before  the  woman 
has  been  left  too  long  in  the  second  stage,  fistulse  have  become  less  and 
less  frequent. 


756  FORCEPS 

From  the  above  it  is  seen  that  sloughing  may  occur  either  from  neglect 
to  use  the  forceps  at  the  proper  time,  or  from  too  forcible  or  too  continuous 
traction  upon  the  instrument  when  used. 

Fetal  Dangers. — The  dangers  to  the  fetus  in  a  forceps  delivery  are 
three:  Compression,  fracture,  and  laceration. 

Compression. — A  too  long  and  too  forcible  extraction  of  a  child  through 
a  parturient  canal  too  .small  for  the  fetal  head  in  question  may  cause 
a  cerebral  compression  and  hemorrhage  and  result  either  in  fetal  death 
at  the  time  of  delivery  or  soon  after,  or  in  cerebral  impairment,  perhaps 
idiocy,  later  in  life.  On  the  other  hand,  a  case  left  too  long  in  need  of 
forceps  delivery  may  have  just  as  serious  compression  and  with  just  as 
serious  consequences.  This  is  the  Scilla  and  Charybdis  between  which 
the  skilful  obstetrician  endeavors  to  safely  steer  the  fetal  bark. 

Frachire. — Fracture  of  the  fetal  skull  is  possible,  but  usually  occurs 
either  from  an  improper  application  of  the  forceps  or  from  an  attempt 
to  deliver  a  head  too  large  for  the  given  canal. 

Lacerations. — Lacerations  of  the  fetal  scalp,  face,  or  neck  usually 
occur  from  one  or  more  of  the  following  causes:  1.  From  an  improper 
application  of  the  forceps  to  the  child's  head.  The  instrument  is  con- 
structed to  be  applied  to  the  sides  of  the  child's  head,  i.  e.,  along  the 
occipitomental  diameter.  If  it  grasps  the  head  with  one  blade  over  an 
eye  and  the  other  over  the  occiput,  or  if  one  blade  reaches  down  on  the 
neck  and  the  other  over  the  forehead,  the  forceps  is  apt  to  slip  and 
lacerati(ms  occur. 

2.  If  traction  is  made  upon  the  force])s  before  the  blades  are  properly 
locked,  the  blades  are  not  parallel  and  the  edge  of  one  at  least  is  apt 
to  cut  into  the  tissues  of  the  scalp. 

3.  Slipping  of  the  forceps  from  any  cau.se  usually  produces  lacera- 
tions of  the  fetal  scalp  or  face. 

Varieties  of  Forceps  Operations. — For  purposes  of  description  and 
record,  three  varieties  of  forceps  operations  are  recognized: 

1.  The  high-forceps  operation,  when  the  instrument  is  applied  to  a 
head  of  which  the  greatest  biparietal  diameter  has  not  passed  the  brim 
plane.    This  head  may  be  floating  or  engaged. 

2.  The  medium-forceps  operation,  when  the  head  lies  in  the  cavity  of 
the  pelvis,  i.  e.,  when  the  greatest  biparietal  diameter  has  passed  the 
brim  plane. 

3.  The  low-forceps  operation,  when  the  head  lies  on  the  pelvic  floor, 
i.  e.,  when  the  greatest  biparietal  diameter  has  passed  the  plane  of  the 
bony  outlet.    In  this  case  the  caput  is  usually  in  sight. 

The  frequency  of  the  indication  for  the  ditterent  varieties  of  forceps 
operation  may  be  seen  from  the  following  statistics  of  the  Sloane 
Hospital. 

In  the  2468  forceps  operations  occuring  in  20,000  consecutive  deliveries 
there  were: 

1778  low  operations 8.90  per  cent.,  or  1  to  11 

472  medium  operations 2.30  per  cent.,  or  1  to  43 

218  high  operations 1 .09  per  cent.,  or  1  to  92 


TECH  NIC  OF  THE  FORCEPS  OPERATION 


757 


Of  the  1778  low-forceps  operations,  1453  were  performed  in  primi- 
gravidse,  or  81.7  per  cent.,  and  325  were  performed  in  multigravidse,  or 
18.3  per  cent.  Of  the  472  medium- 
forceps  operations,  324  were  per- 
formed in  primigravidfe,  or  68.6 
per  cent.,  and  148  were  performed 
in  multigravidae,  or  31.4  per  cent. 

Of  the  218  high-forceps  opera- 
tions, 87  were  performed  in  primi- 
gravidse,  or  40  per  cent.,  and  131 
were  performed  in  multigravidee, 
or  60  per  cent. 

Technic  of  the  Forceps  Opera- 
tion.—  Position  of  the  Patient. — 
In  America  it  is  generally  agreed 
that  whether  a  normal  delivery  is 
conducted  with  the  patient  on  her 
back  or  on  her  side,  in  an  obstetric 
operation  like  a  forceps  delivery, 
there  is  only  one  position  for  the 
patient,  i.  e.,  the  so-called  lith- 
otomy position;  the  patient  lying 
on  her  back,  at  the  edge  of  the 
bed  or  table,  with  knees  elevated  and  held  in  this  position  by  some 
variety  of  leg-holder.  In  a  hospital  the  feet  are  usually  held  in  canvas 
stirrups  attached   to  metal   uprights   at  the  foot  of  the  table,  but  in 


Fig.  456.— Robb's  leg-holder. 


Fig.  457. — Robb's  leg-holder  in  position. 


private  practice  a  canvas  leg-holder,  usually  called  Robb's  leg-holder  (see 
Fig.  456),  which  will  pass  over  one  shoulder  and  then  about  each  knee 


758 


FORCEPS 


(see  Fig.  4n7),  will,  on  accomit  of  its  light  weight  and  small  compass, 
generally  be  found  most  convenient. 

In  cases  of  emergency  a  folded  or  twisted  sheet  may  be  used  for  this 
purpose,  but  it  is  wiser  to  carry  a  canvas  leg-holder  in  one's  obstetric 
l)ag.  The  dorsal  position  has  the  further  advantage  that  the  fetal  heart 
can  l)e  watched  by  an  assistant  during  the  forceps  delivery,  and  after 
the  delivery  of  the  child,  the  fundus  may  be  held  and  if  necessary 
manipulated  without  change  of  posture. 


Fig.  458 


Preparation  of  the  Patient. — Before  the  use  of  the  forceps  the  vulva 
should  ])e  closely  clipped  or  shaved  if  this  has  not  been  ])reviously 
attended  to.  The  bladder  should  be  emptied  either  voluntarily  or  by 
catheter,  not  only  because  all  the  available  space  in  the  pelvis  is  desired 
for  ease  of  extraction,  but  also  because  severe  traction  and  pressure 
against  a  distended  bladder  would  endanger  that  viscus.  Furthermore, 
if  a  distended  portion  of  the  bladder  is  caught  in  front  of  the  head, 
traction  upon  the  latter  would  tend  to  loosen  the  bladder  from  its  pubic 


TECH  NIC  OF  THE  FORCEPS  OPERATION  759 

attachments  and  favor  cystocele.  It  is  taken  for  granted  that  the 
rectnm  has  been  emptied  by  enema  earlier  in  the  labor,  but  it  is  fitting 
that  attention  should  be  directed  to  the  fact  that  the  rectum  as  well  as 
the  bladder  should  be  emptied  in  all  forceps  operations. 

After  emptying  the  bladder,  the  vulva  and  inner  surfaces  of  the  thighs 
should  be  thoroughly  scrubbed  with  sterile  soap  and  water,  disinfected 
and  properly  draped,  especial  care  being  taken  to  cover  the  rectum  and 
to  leave  exposed  only  the  vulvar  field;  the  surroundings  of  this  field 
being  covered  with  sterile  stocking-drawers  and  sterile  towels  or  sheets 
(see  Fig.  458). 

The  patient  should  be  anesthetized  until  she  is  thoroughly  under 
control.  The  author  was  once  called  upon  to  operate  upon  a  case  of 
ruptured  uterus  in  a  woman,  who  being  only  partially  anesthetized, 
pushed  over  her  obstetrician,  after  he  applied  the  forceps,  raised  herself 
upon  the  bed  and  sat  down  upon  the  handles  of  the  instruments  as  they 
projected  from  the  vulva,  thus  causing  an  incomplete  rupture  of  the  uterus. 

Application  of  the  Forceps. — Before  discussing  the  details  of  the  dif- 
ferent forceps  operations,  the  meaning  of  the  term  "application"  should 
be  made  clear.  Two  different  methods  of  applying  the  forceps  for  the 
delivery  of  a  child  are  possible: 

1.  The  two  blades  may  be  introduced,  one  to  one  side  of  the  pelvis 
and  the  other  to  the  other  side,  and  then  locked,  grasping  any  part  of  the 
fetal  head  which  lies  between  them.  This  was  for  many  years  the  method 
used  in  England  and  has  been  generally  known  as  the  English  method, 
or  the  pelvic  application.  This  method  considers  only  the  sides  of  the 
pelvis  in  the  introduction  of  the  forceps  and  regards  the  fetal  head  chiefly 
as  a  foreign  body  to  be  extracted  from  it. 

2.  In  the  medium-  and  low-forceps  operation  the  long  diameter  of  the 
head  usually,  but  by  no  means  always,  lies  in  the  anteroposterior  diam- 
eter of  the  outlet  and  the  blades  introduced  one  on  each  side  of  the  pelvis 
would  under  these  circumstances  be  applied  to  the  sides  of  the  child's 
head  but  without  regard  to  whether  the  occiput  was  anterior  or  posterior. 

The  application  sought  today  by  all  skilled  obstetricians  is  the  cephalic 
application,  sometimes  called  the  "continental  method,"  as  distinguished 
from  the  English.  In  this  application  of  the  forceps,  the  blades  are 
applied  to  the  sides  of  the  child's  head  whatever  its  position  in  the 
pelvis.  This  method  presupposes  an  accurate  diagnosis  of  the  position 
of  the  child  before  the  use  of  the  instrument. 

The  cephalic  application  of  the  forceps  is  not  only  more  scientific 
in  favoring  the  natural  mechanism  of  labor,  but  it  brings  the  pressure  of 
the  instrument  upon  that  diameter  of  the  fetal  head  which  is  least  liable 
to  injury  from  it. 

The  steps  of  the  operation  may  be  regarded  as  follows: 

1.  Diagnosis  of  the  presentation  and  position. 

2.  Introduction  of  the  blades. 

3.  Locking  of  the  blades. 

4.  Traction. 

5.  Removal. 


7()0  FORCEPS 

Diagnosis  of  the  Presentation  and  Position  of  the  Child. — So  important 
is  it  that  the  obstetrician  should  know  just  the  problem  with  which  he 
has  to  deal,  that  the  author  would  lay  stress  upon  the  need  for  an  accu- 
rate diagnosis  of  the  presentation  and  position  of  the  child  and  the 
relative  size  of  the  pelvis  before  attempting  the  introduction  of  the 
forceps. 

The  reasons  for  this  are  obvious:  If  it  is  a  breech  presentation  the 
forceps  is  rarely  indicated,  at  least  until  after  the  birth  of  the  shoulders. 
If  it  is  a  \ertex  presentation  with  an  occipitoposterior  position,  the 
forceps  is  usually  not  to  be  introduced  until  at  least  partial  manual 
rotation  of  the  head  has  been  accomplished.  If  the  pelvis  is  too  small 
for  delivery  2^^^  ^"o-?  naturales  the  forceps  should  not  be  used  at  all. 
For  these  reasons  an  accurate  diagnosis  of  the  conditions  present  should 
first  be  made.  If  necessary  for  this  purpose  even  the  whole  hand  shoidd 
be  introduced  into  the  vagina  for  palpation  of  the  sutures  and  fontanelles. 
Many  obstetricians  feel  for  and  identify  the  posterior  ear  as  a  means  of 
diagnosis  of  position,  but  this  is,  as  a  rule,  unnecessary  as  the  sutures  and 
fontanelles  usually  furnish  the  desired  information. 

Methods  of  Introduction  of  the  Blades. — Two  methods  of  introduction 
of  the  forceps  blades  are  possible,  (a)  The  lateral,  (b)  The  posterior. 
The  lateral  introdiiction  consists  in  passing  the  left  blade  to  the  left  side 
of  the  pelvis  and  the  right  blade  to  the  right  side  of  the  pelvis  and  then 
adjusting  the  blades  to  the  sides  of  the  child's  head. 

The  posterior  introduction  consists  in  passing  the  left  blade  along  the 
middle  of  the  posterior  vaginal  wall  with  the  concavity  of  the  blade 
upward,  then  passing  the  right  blade  held  in  the  right  hand,  with  its 
convexity  sliding  along  the  concavity  of  the  left  blade,  until  the  handles 
are  even,  then  rotating  both  blades  simultaneously  until  they  rest  upon 
the  sides  of  the  fetal  head. 

For  normal  cases,  with  occiput  anterior,  the  lateral  method  of  intro- 
duction is  preferable.  The  posterior  introduction  in  these  cases  is  both 
more  diflRcidt  and  more  likely  to  do  harm.  In  fact  the  posterior  intro- 
duction in  its  complete  form  has  never  been  satisfactory  to  the  author, 
but  in  cases  with  occiput  posterior  the  combination  of  the  posterior 
and  lateral  introduction  has  proved  of  very  great  value.  In  these  cases, 
after  manual  rotation  of  the  occiput  as  nearly  forward  as  is  possible, 
the  blade  corresponding  to  the  side  on  which  the  occiput  has  lain  is 
introduced  in  the  median  line  posteriorly  and  rotated  around  to  the 
side  of  the  fetal  head,  thus  holding  and  increasing  the  rotation  accom- 
plished by  the  hand. 

The  other  blade  is  then  introduced  laterally  so  as  to  avoid  rotating 
the  head  in  the  opposite  direction,  and  is  applied  to  the  opposite  side 
of  the  fetal  head.  If  the  position  was  an  L.  O.  P.,  after  manual  rota- 
tion forward  of  the  fetal  head,  the  left  blade  would  be  the  one  to  intro- 
duce first  and  posteriorly  and  after  its  rotation  to  the  side  of  the  fetal 
head  the  right  blade  would  be  introduced  laterally  to  the  right  side  of 
the  pelvis.  Its  shank  and  handle  lying  anteriorly  to  those  of  the  left 
blade,  the  two  would  lock  naturally.    If  the  position  was  an  R.  O.  P., 


TECH  NIC  OF  THE  FORCEPS  OPERATION  761 

after  manual  rotation  forward  of  the  fetal  head,  the  right  blade  would 
be  the  one  to  introduce  first  and  posteriorly  and  after  its  rotation  to  the 
side  of  the  fetal  head,  the  left  blade  would  be  introduced  laterally  to  the 
left  side  of  the  pelvis.  The  shank  and  handle  of  the  left  blade  will  now 
lie  anterior  to  those  of  the  right,  and  the  two  blades  will  not  lock  until 
the  handle  of  the  left  blade  has  been  carried  underneath  that  of  the  right. 

With  a  little  adjustment  of  the  two  blades  they  will  now  lock  with 
ease. 

Technic  of  Introduction  of  the  Forceps  Blades. — In  all  methods  of 
introduction  of  the  forceps  blades,  save  in  the  cases  where  the  head  is 
distending  the  vulvar  outlet,  the  fingers  of  one  hand  should  be  introduced 
into  the  vagina  far  enough  to  feel  the  cervix  or  to  ascertain  that  the 
cervix  had  receded  out  of  reach,  the  function  of  these  vaginal  fingers 
being  to  guide  the  forceps  blade  into  the  cervical  canal. 

In  the  lateral  method  of  introduction  the  left  blade  is  usually  the 
first  to  be  introduced  and  the  fingers  of  the  right  hand  are  introduced 
into  the  vagina  to  serve  as  a  guiding  groove  along  which  the  left  blade 
is  to  pass  into  the  cervical  canal  and  on  to  the  side  of  the  fetal  head. 

In  holding  the  left  blade  for  introduction,  the  handle  is  taken  lightly 
between  the  thumb,  fore-  and  middle  fingers  of  the  left  hand  and  is  raised 
and  held  well  to  the  right  above  the  pubes  so  that  the  curve  of  the  con- 
cavity of  the  blade  will  correspond  to  the  convexity  of  that  side  of  the 
fetal  head;  the  blade  is  then  passed  along  the  concavity  of  the  vaginal 
fingers  which  insure  its  entrance  into  the  cervical  canal,  rather  than 
passing  to  the  outer  side  of  the  cervix,  and  is  then  made  to  pass  gently 
to  the  side  of  the  fetal  head.  As  this  is  done  the  handle  is  gently  depressed, 
carried  to  the  median  line  and  allowed  to  rest  on  the  edge  of  the  perineum. 

The  fingers  of  the  left  hand  are  then  introduced  into  the  vagina  as  a 
guide  for  the  right  blade  to  the  cervical  canal,  the  handle  of  the  right 
blade  being  held  lightly  in  the  fingers  of  the  right  hand  as  was  the  left 
handle  in  the  left  hand;  at  first  held  high  and  to  the  left  above  the 
pubes,  then  gradually  depressed  and  carried  to  the  median  line  until  it 
rests  upon  the  left  blade  just  introduced.  The  shanks  of  the  two  blades 
are  now  adjusted  until  they  lock  easily. 

When  the  first  blade  is  introduced  posteriorly  the  handle  of  the  instru- 
ment may  be  held  lightly  in  the  grasp  of  the  whole  hand;  first  elevated 
in  the  median  line  then  gradually  depressed  as  the  concavity  of  the 
blade  slides  along  the  convexity  of  the  head. 

Loching  of  the  Forceps  Blades. — ^AYhen  the  blades  are  properly  applied 
to  the  sides  of  the  fetal  head  they  should  lock  without  difficulty,  and  it 
is  extremely  important  that  the  obstetrician  should  see  that  the  blades 
are  carefully  locked  before  any  traction  is  exerted.  With  blades  locked, 
the  upper  and  lower  edges  of  the  two  blades  lie  in  two  parallel  planes 
and  are  not  likely  to  cut  the  scalp  when  traction  is  made  upon  the 
handles.  If  the  blades,  on  the  other  hand,  are  not  completely  locked 
when  traction  is  exerted,  the  edges  of  the  two  blades  do  not  lie  in  parallel 
planes,  and  the  lower  edge  of  one  or  both  blades  is  apt  to  cut  the  scalp  or 
the  cheek. 


762  FORCEPS 

Traction. — After  the  locking  of  tlie  forceps  blades  traction  is  in  order, 
hut  at  first  should  he  only  tentative  with  one  hand  on  the  handles  of 
the  instrument,  while  the  fingers  of  the  other  hand  are  kept  against  the 
fetal  head  to  make  sure  that  the  head  aihances  with  the  traction  and 
that  the  blades  are  not  slipj)ing  from  the  head.  In  the  exercise  of  trac- 
tion upon  the  forceps  two  principles  should  always  be  observed: 

1.  The  traction  should  always  be  in  the  axis  of  the  parturient  canal, 
this  varying  with  the  height  of  the  head  in  the  pelvis. 

2.  The  traction  should  be  intermittent,  thus  imitating  nature  in  her 
intermittent  uterine  contractions  and  allowing  opportunity  for  the 
reestablishment  both  of  the  fetal  circulation  and  the  circulation  of  the 
soft  parts  of  the  parturient  canal.  In  addition  to  regular  intermission 
in  the  traction  it  is  advisable  also  to  intermit  in  the  pressure  of  the 
blades  upon  the  fetal  head  by  separating  the  handles  of  the  instruments 
between  the  tractions.  Great  care  should  be  taken,  however,  to  see  that 
the  blades  are  carefully  locked  again  before  traction  is  renewed,  as  other- 
wise cutting  of  the  scalp  or  cheek,  as  already  mentioned,  is  apt  to  occur. 

Removal  of  the  Blades. — As  soon  as  the  head  has  been  brought  suffi- 
ciently low  in  the  parturient  canal  to  allow  its  further  delivery  to  be 
under  the  control  of  the  hands  of  the  obstetrician,  the  blades  should  be 
removed  for  two  reasons: 

1.  Even  the  thin  blades  of  the  forceps  occupy  a  certain  amount  of 
room,  and  their  absence  diminishes  the  tension  to  which  the  vulvar  outlet 
is  subjected. 

2.  The  head  can  usually  be  delivered  more  gradually  and  under  more 
perfect  control  by  the  hands  than  by  the  forceps,  and  hence  laceration 
is  avoided  by  removal  of  the  blades  before  the  complete  delivery  of  the 
head. 

The  ease  with  which  the  solid  blade  is  removed,  as  compared  with  the 
fenestrated,  is  easily  demonstrated  at  this  time. 

Forceps  Delivery  in  Occipitoposterior  Positions  of  the  Vertex.— As 
already  indicated  in  discussing  the  introduction  of  the  forceps  blades, 
the  ideal  method  of  forceps  delivery  in  occipitoposterior  positions  is 
to  apply  the  instrument  to  the  sides  of  the  child's  head  after  manual 
rotation  has  brought  the  occiput  in  front  of  the  transverse  diameter  of 
the  pelvis. 

Thus  in  an  R.  O.  P.  position,  rotate  manually  to  an  R.  O.  A.,  introduce 
the  right  blade  first  in  the  median  line  posteriorly  and  slide  it  around 
the  right  side  of  the  pelvis  until  it  lies  on  the  right  side  of  the  child's 
head ;  then  introduce  the  left  blade  to  the  left  side  of  the  pelvis  and  apply 
it  to  the  left  side  of  the  child's  head  and  adjust  the  handles  so  that  the 
left  lies  below  the  right;  then  lock  the  blades  and  begin  traction.' 

In  certain  cases,  however,  where  it  is  impossible  to  rotate  the  head 
manually,  the  double  application  of  the  forceps  may  be  necessary. 

Double  Application  of  the  Forceps.  Scanzoni's  Maneuver. — In  this 
method  of  forceps  delivery  in  occipitoposterior  positions,  the  blades  are 
applied  to  the  sides  of  the  fetal  head  with  occiput  still  posterior  and 
the  concavity  of  the  pelvic  curve  of  the  instrument  anterior. 


DELIVERY  BY  MEANS  OF  THE  AXIS-TRACTION  FORCEPS     763 

The  head  is  brought  down  to  the  floor  of  the  pelvis  and  the  rotation 
of  the  occiput  forward  is  then  favored  by  gentle  manipulation  with  the 
instrument  as  follows:  Flexion  of  the  head  is  favored  by  upward  trac- 
tion on  the  forceps;  the  handles  are  then  turned  slowly  and  gently  to 
the  side  opposite  to  the  occiput  and  then  allowed  to  fall  slowly  downward 
and  backward.  This  brings  about  the  rotation  of  the  occiput  forward, 
but  leaves  the  forceps  with  the  convexity  of  the  pelvic  curve  anterior, 
i.  e.,  the  forceps  is  reversed.  The  instrument  is  now  withdrawn,  reapplied 
as  in  an  occipito-anterior  position  and  the  delivery  completed. 

Delivery  by  Means  of  the  Axis-traction  Forceps. — In  many  cases  of 
the  high-forceps  operation,  and  occasionally  in  the  median  operation, 
delivery  is  difficult  on  account  of  the  difficulty  of  exerting  traction 
in  the  axis  of  the  superior  strait,  which  if  continued  downward  would 
pass  through  the  lower  part  of  the  sacrum.  The  presence  of  the  coccyx 
and  the  perineum  rendering  impossible  sufficient  depression  of  the 
handles  of  the  forceps  to  exert  traction  in  this  direction,  much  of  the 
traction  force  is  wasted  by  drawing  the  head  against  the  symphysis  pubis 
rather  than  downward  in  the  axis  of  the  parturient  canal. 


Fig.  459. — Pajot's  maneuver. 


This  defect  in  the  ordinary  forceps  was  recognized  nearly  a  century 
before  Tarnier,  in  1877,  devised  the  instrument  which  bears  his  name, 
and  two  suggestions  were  made  for  overcoming  the  difficulty:  one  by 
Saxtorph,  was  to  attach  tapes  or  traction  strings  to  the  fenestree  of  the 
blades  and  make  traction  upon  these  as  well  as  upon  the  handles  of  the 
instrument.  The  other,  usually  called  Pajot's  maneuver  (see  Fig.  459) 
was  to  make  strong  downward  pressure  with  one  hand  near  the  lock  of 
the  instrument,  while  the  other  made  traction  on  the  handles. 

The  most  perfect  instrument  for  carrying  out  the  principle  of  axis 
traction  is  that  of  Tarnier  (seen  in  Figs.  454  and  455).  It  consists  of  the 
long  French  instrument,  with  French  lock  and  fenestrated  blades,  and 
in  the  shank  of  each  blade  near  the  fenestra  an  adjustable  traction  rod 
is  inserted,  which  when  not  in  use  is  snapped  over  a  pin  lower  down  on 
the  shank.  When  about  to  be  used,  the  traction  rods  are  freed  from  the 
holding  pins  and  fitted  into  a  common  handle  and  cross-bar,  which  has 
nearly  a  universal  joint.  The  ordinary  handles  of  the  instrument  are 
not  employed  for  traction,  while  the  traction  rods  are  in  use,  but  serve 


764  FORCEPS 

to  indicate  the  direction  in  which  traction  sliould  be  made.  Traction 
is  exerted  on  the  cross-bar  handle  in  such  a  direction  as  will  keep  the 
traction  rods  nearly  parallel  to  the  shanks  of  the  blades  and  about  1  cm. 
below  them.  When  this  simple  rule  is  followed  the  traction  is  made  in 
the  axis  of  the  parturient  canal;  is  accompanied  by  the  least  friction,  and 
is  most  effective.  While  the  ordinary  handles  are  not  used  for  traction 
in  the  high  operation  with  this  instrument,  the\'  are  useful  for  two 
purposes:  (1)  They  serve  as  a  guide  to  the  direction  for  traction,  and 
(2)  they  are  often  useful  in  favoring  rotation  of  the  head  while  traction 
is  made  on  the  traction  rods.  While  some  obstetricians  use  this  instru- 
ment for  all  forceps  operations,  without  the  traction  rods  for  low  and 
median  operations,  and  with  the  traction  rods  for  the  high  operation, 
the  author  regards  the  instrument  as  too  complicated  and  cumbersome 
for  the  low  and  ordinary  medium  operations,  and  prefers  for  this  work 
the  Tucker-McLane  forceps  seen  in  Figs.  452  and  453,  reserving  the  axis- 
traction  instrument  for  the  difficult  high  operations. 

Technic  of  Delivery  with  the  Axis-traction  Forceps. — Whether  the  trac- 
tion rods  of  the  axis-traction  forceps  are  to  be  used  or  not,  the  blades 
are  introduced  singly  with  traction  rods  snapped  over  the  holding  pins 
and  without  the  handle  and  cross-bar.  Each  blade  is  introduced  in  a 
manner  already  described  for  the  simple  instrument,  the  left  blade  being 
the  one  usually  introduced  first.  After  introduction  of  the  blades  their 
shanks  are  adjusted  and  locked  with  the  thumb-screw  of  the  French 
lock. 

The  compression  screw  lying  on  the  anterior  surface  of  the  shanks 
just  in  front  of  the  handles  should,  in  the  judgment  of  the  author,  be  used 
only  to  maintain  the  amount  of  pressure  of  the  blade  upon  the  head, 
which  is  given  by  the  obstetrician  when  the  blades  are  locked,  not  for 
the  purpose  of  increasing  this  compression  as  the  delivery  proceeds.  The 
blades  having  been  introduced  and  locked,  the  traction  rods,  if  to  be  used, 
are  unsnapped  from  their  holding  pins  and  the  cross-bar  handle  adjusted 
to  them. 

Traction  is  now  exerted  upon  the  cross-bar  in  such  a  way  that  the 
traction  rods  are  parallel  to,  and  just  below,  the  regular  handles,  until 
the  head  has  been  brought  sufficiently  low  to  be  easily  controlled  by  the 
hand  upon  the  perineal  surface.  The  cross-bar  handle  should  then  be 
disconnected;  the  traction  rods  snapped  upon  the  holding  pins;  the 
lock  unscrewed  and  the  blades  removed  from  the  head. 

Forceps  Delivery  in  Face  Presentation. — It  is  well  recognized  that 
with  a  normal  pelvis  and  a  full-sized  fetus,  delivery  of  the  head  in  face 
presentation  with  chin  persistently  posterior  is  impossible,  hence  the  use 
of  the  forceps  solely  as  a  tractor  in  this  presentation  and  position  is  inap- 
plicable. In  a  few  exceptional  cases,  however,  in  skilled  hands,  the  forceps 
may  be  used  to  favor  rotation  of  the  chin  to  the  front,  this  motion  of 
rotation  being  combined  w^th  traction  and  thus  an  otherwise  impossible 
delivery  per  mas  naiurales  is  accomplished. 

With  the  face  in  a  transverse  position,  or  especially  in  a  mento-anterior 
position,  the  indications  for  the  use  of  the  forceps  are  practically  the 


FORCEPS  DELIVERY  IN  FACE  PRESENTATION 


765 


same  as  in  a  vertex  presentation  with  head  lying  transversely  or  in  an 
occipito-anterior  position,  viz.,  insufficient  expulsive  power,  or  insuffi- 
cient progress.  In  both  cases  the  blades  are  applied  to  the  sides  of  the 
fetal  head  along  the  occipitomental  diameter  (see  Figs.  460  and  461), 
but  while  in  vertex  cases  the  application  desired  is  one  with  the  pelvic 


Fig.  460. — Forceps  application.     Vertex  presentation. 

curve  of  the  forceps  directed  toward  the  back  of  the  fetal  neck,  in  face 
cases  the  application  desired  is  one  with  pelvic  curve  directed  toward 
the  front  of  the  fetal  neck.  In  vertex  cases  it  is  the  occiput  which  lies 
nearer  the  lock,  while  in  face  cases  it  is  the  chin.  In  vertex  cases  flexion 
is  the  motion  desired  until  the  presenting  part  has  engaged  under  the 
symphysis,  while  in  face  cases  extention  is  the  motion  desired. 


Fig.  461. — Forceps  application.     Face  presentation. 

If  either  the  occiput  or  the  chin  lies  in  the  transverse  diameter  of  the 
pelvis,  rotation  to  the  anteroposterior  diameter  is  desired. 

In  a  forceps  delivery  of  a  face  presentation,  with  chin  anterior,  the 
blades  are  applied  to  the  sides  of  the  head  and  traction  is  made  in  a  down- 
ward direction  until  the  chin  emerges  from  beneath  the  symphysis; 


76G  FORCEPS 

the  handles  are  then  elevated  and  traction  exerted  in  an  npward  direction, 
the  nose,  eyes  and  forehead  sweepin<2;  in  turn  over  the  fourchette. 

The  Use  of  Forceps  in  a  Breech  Presentation. — In  a  complete  breech 
presentation,  where  the  feet  lie  near  the  breech,  the  forceps  is  practically 
never  indicated  for  the  delivery  of  the  breech  itself,  as  one  or  other  foot 
can  be  })rought  down  and  the  foot  and  leg  used  as  a  tractor. 

In  the  frank  breech,  with  legs  extended,  this  statement  also  usually 
applies,  although  the  hand  of  the  obstetrician  may  have  to  be  intro- 
duced nearly  to  the  fundus  uteri  to  reach  the  foot.  In  very  rare  cases, 
however,  when  the  frank  breech  is  impacted  in  the  pelvis,  and  the  uterus 
so  contracted  that  the  introduction  of  the  hand  would  be  accompanied 
b}^  the  da,nger  of  uterine  rupture,  the  use  of  the  forceps  ma>'  be  indi- 
cated as  a  means  of  delivery.  In  such  instances  it  must  be  borne  in  mind 
that  the  trochanters  are  the  parts  of  the  breech  best  suited  for  the 
application  of  the  forceps. 

With  one  blade  applied  to  one  trochanter  and  the  other  to  the  other 
one,  traction  may  be  exerted  which  will  accomplish  the  delivery  of  the 
breech  without  injury  to  the  child. 

Forceps  Delivery  of  the  After-coming  Head. — The  Mauriceau-Smellie- 
\>it  method  of  delivering  the  head,  with  the  two  fingers  of  one  hand  in 
the  fetal  mouth  to  maintain  flexion,  and  the  fingers  of  the  other  hand 
on  the  fetal  shoulders  to  exert  traction  (see  Fig.  424),  will  usually  succeed 
in  delivering  the  after-coming  head  without  the  use  of  any  instrument. 
In  rare  instances,  however,  where  the  obstetrician  is  unable  to  complete 
the  delivery  within  the  time  necessary  to  secure  a  living  child,  the  forceps 
serves  a  most  useful  purpose.  In  these  conditions,  with  the  occiput 
anterior,  the  body  of  the  child  is  raised  by  an  assistant  or  nurse  and  the 
blades  of  the  instrument  are  applied  underneath  the  body,  to  the  sides 
of  the  child's  head,  along  the  occipitomental  diameter,  the  chin  being 
near  the  shanks  of  the  forceps  and  the  pelvic  curve  of  the  instrument 
being  directed  toward  the  back  of  the  child's  neck.  With  the  patient 
in  the  lithotomy  position,  traction  is  made  forward  and  upward,  the 
mouth,  nose,  eyes  and  forehead  sweeping  over  the  fourchette  as  the  back 
of  the  child  approaches  the  mother's  abdomen. 

In  the  rare  cases  where,  in  the  attempted  delivery  of  the  after-coming 
head,  the  obstetrician  has  not  succeeded  in  rotating  the  occiput  to  the 
front,  some  recommend  the  introduction  of  the  blades  above  the  child's 
body,  the  concavity  of  the  pelvic  curve  being  directed  to  the  front  of 
the  child's  neck.  In  such  cases  traction  would  be  made  downward  and 
backward  as  the  back  of  the  child  approaches  the  back  of  the  mother. 

Mortality  of  Forceps  Operation. — Maternal. — In  the  author's  series 
of  2468  forceps  operations  there  were  30  maternal  deaths,  or  a  maternal 
mortality  of  1.2  per  cent.  It  should  be  remembered,  however,  that 
])ractically  all  of  the  deaths  were  caused  l)y  the  condition  of  the  mother 
before  the  instrument  was  introduced.  Furthermore,  the  general 
maternal  mortality  of  the  Sloane  Hospital,  in  a  consecutive  series  of 
20,000  deliveries,  was  1.09  per  cent.,  so  that  the  increased  mortality 
in  forceps  operations  was  not  great. 


MORTALITY  OF  FORCEPS  OPERATION  7G7 

Fetal  Mortality. — The  fetal  mortality  is  seen  to  vary  with  the  type  of 
operation.  Thus  in  the  1778  low-forceps  operations  there  were  180 
fetal  deaths,  or  a  fetal  mortality  of  approximately  10  per  cent.  In  the 
472  medium  operations  there  were  94  fetal  deaths,  a  mortality  of  19.2 
per  cent.  In  the  218  high-forceps  operations  there  were  84  fetal  deaths, 
a  mortality  of  38.5  per  cent.  The  total  fetal  mortality  in  the  2468 
forceps  operations  of  all  types  was  358,  or  14.5  per  cent.  This  total 
mortality  includes  not  only  stillbirths,  but  death  of  the  children  from 
any  cause  while  the  mother  remained  in  the  hospital.  The  stillbirths 
in  forceps  operations  of  different  types  were  markedly  less.  Thus  in 
the  1778  low-forceps  operations  the  stillbirths  were  4  per  cent.;  in  the 
472  medium-forceps  operations  the  stillbirths  were  8.5  per  cent.;  in  the 
218  high-forceps  operations  the  stillbirths  were  26.2  per  cent.  Total 
stillbirths  were  6.9  per  cent. 


CHAPTER  XXVI. 
VERSION. 

Version  is  the  substitution  of  some  other  part  of  the  fetus  for  that 
which  presents  at  the  superior  strait.  By  version  a  transverse  or  an 
obhque  presentation  is  changed  into  one  which  is  longitudinal,  or  one 
pole  of  the  fetus  is  substituted  for  the  other. 

Version  is  classified  either  according  to  the  part  which  is  made  to 
present  or  according  to  the  method  b}'  which  the  change  is  brought 
about.  According  to  the  former  classification,  version  is  cephalic 
when  the  head  is  made  to  present;  jjelvic  when  the  breech  is  made  to 
present;  podaJic  when  the  feet  are  made  to  present.  Classified  according 
to  method,  version  is  called  external  when  the  manipulations  are  per- 
formed externally  through  the  abdominal  wall;  it  is  called  combined 
or  bipolar  or  Braxton  Hicks  version  when  one  or  two  fingers  of  one 
hand  are  introduced  through  the  cervix,  while  the  other  hand  assists 
in  the  manipulation  by  working  from  without  through  the  abdominal 
wall.  It  is  called  internal  version  when  one  hand  is  introduced  into  the 
cavity  of  the  uterus.  The  difference  between  internal  version  and 
combined  or  bipolar  version,  as  performed  today,  depends  chiefly  upon 
the  amount  of  the  hand  introduced  into  the  uterus,  as  in  both  cases  the 
other  hand  assists  by  manipulations  through  the  abdominal  wall.  In 
internal  version  the  whole  hand  is  in  the  uterine  cavitj',  while  in  com- 
bined version  only  the  fingers  are  in  the  uterus,  the  rest  of  the  hand 
being  in  the  vagina. 

Indications. — The  indications  for  the  performance  of  version  are 
numerous  and  vary  with  the  variety,  but  in  general  they  may  be  stated 
as  follows: 

1 .  To  Exchange  a  Less  Favorable  Presentation  for  One  More  Favorable 
for  Delivery. — As,  for  instance,  to  change  a  transverse  to  a  longitudinal 
presentation. 

2.  To  Secure  a  Speedy  Delivery. — As,  for  instance,  in  eclampsia. 

3.  To  Accomplish  Delivery  in  a  Flat  Pelvis. — The  employment  of  version 
for  this  purpose  is  based  on  the  fact  that  as  the  biparietal  diameter  of 
the  fetal  skull  measures  9.25  cm.  and  the  bimastoid  diameter  measures 
only  7.5  cm.,  the  vault  of  the  fetal  head  is  broader  than  its  base.  Hence, 
if  the  fetus  is  delivered  by  the  breech,  the  smaller  end  of  the  cephalic 
wedge  is  first  brought  through  the  pelvic  canal  and  delivery  through  a 
flat  pelvis  is  thus  facilitated. 

4.  To  Furnish  a  Uterine  Tamponade  by  Partial  Breech  Extraction.^This 
is  especially  employed  in  a  placenta  previa  to  prevent  hemorrhage  by 
pressure  upon  the  placental  site. 

( 768 ) 


METHODS  OF   VERSION  769 

5.  To  Lessen  Pressure  upon  the  Cord  in  Certain  Cases  of  Prolapse  of  the 
Cord. — ^As,  for  instance,  where  maintenance  of  replacement  is  impossible. 

In  studying  the  above  group  of  indications  it  will  be  seen  that,  save 
perhaps  in  the  first,  it  is  podalic  version  which  is  indicated  and  best 
meets  the  situation. 

METHODS  OF  VERSION. 

External  Version.— As  already  stated,  in  external  version  all  manipu- 
lations are  conducted  externally;  i.  e.,  the  hands  of  the  obstetrician  work 
through  the  abdominal  wall  of  the  patient,  pushing  out  of  the  pelvic 
brim  the  portion  of  the  fetus  undesired  there  and  pushing  down  the 
fetal  part  which  it  is  desired  to  have  present. 

Conditions. — For  the  successful  accomplishment  of  external  version  the 
following  conditions  must,  as  a  rule,  be  present: 
The  liquor  amnii  present. 
The  fetus  freely  movable. 
The  uterine  and  abdominal  walls  relaxed. 
The  abdominal  wall  not  too  fat. 

Indications.- — ^As  a  rule  external  version  is  only  indicated  during  preg- 
nancy or  very  early  in  labor.  It  finds  its  chief  indications  in  a  breech 
presentation  which  it  is  desired  to  change  to  a  vertex  and  in  an  oblique 
or  transverse  presentation  which  it  is  desired  if  possible  to  change  to  a 
vertex,  or  failing  in  that,  to  a  breech  presentation. 

Technic. — With  bowels  and  bladder  empty,  the  patient  should  lie 
on  the  back  with  thighs  flexed  and  abdomen  bared  and  as  thoroughly 
relaxed  as  possible.  The  exact  presentation  and  position  of  the  fetus 
should  be  carefully  determined  and  then  the  pole  of  the  fetus  which  it 
is  desired  to  have  present  should  be  gently  pressed  with  one  hand  toward 
the  pelvic  brim,  while  with  the  other  hand  the  undesired  pole  is  gently 
moved  away  from  the  brim  in  the  opposite  direction  (see  Fig.  462) . 

In  a  breech  presentation  the  author  usually  prefers  to  turn  the  fetus 
as  indicated  by  the  arrows,  maintaining  flexion.  In  a  few  instances  it 
may  be  easier  to  turn  in  the  opposite  direction. 

In  a  transverse  or  shoulder  presentation  the  manipulations  may  be 
conducted  with  the  obstetrician  standing  either  above  or  below  the 
pelvis  of  the  patient  (see  Figs.  463  and  464).  The  author  usually  prefers 
the  former. 

It  is  the  experience  of  most  obstetricians  that  while  in  many  cases, 
as  for  instance,  in  breech  presentations  with  lax  abdominal  walls  it  is 
easy  to  perform  the  version,  it  is  extremely  difficult  to  maintain  the 
result,  and  one  is  often  disappointed  at  the  end  of  a  day  or  two  to  find 
again  a  breech  presentation.  The  use  of  a  pad  on  the  side  of  head  and 
breech  toward  which  they  tend  to  move  and  a  snug  abdominal  binder 
will  sometimes  maintain  the  corrected  presentation,  and  as  soon  in  the 
course  of  the  labor  as  the  cervix  is  sufficiently  dilated  to  justify  rupture 
of  the  membranes,  the  escape  of  the  liquor  amnii  and  contraction  of 
the  uterus  will  prevent  the  return  of  the  malpresentation.  So  long  as 
there  is  very  little  risk  in  attempting  the  correction  of  a  malpresentation 
49 


770 


VERSION 


by  external  version  it  is  i)erfectly  justifiable  to  try  it  even  if  disappoint- 
ments are  common. 

Combined  or  Bipolar  Version. — In  this  method  which  was  perfected 
and  popularized  by  Braxton  Hicks  and  occasionally  called  by  his  name, 
one  hand  in  the  vagina  with  two  fingers  in  the  cervix  works  on  one  pole 
of  the  fetus,  while  the  other  hand  externally  works  through  the  abdominal 
wall  on  the  other  pole  of  the  fetus. 


Fig.  4G2. — External  version  in  a  breech  presentation. 


Conditions. — For  this  method  of  version  the  liquor  amnii  must  be 
present  or  only  recently  drained  away.  The  fetus  must  be  movable. 
The  cervix  must  be  sufficiently  dilated  to  admit  one  or  two  fingers.  The 
abdominal  and  uterine  walls  must  be  relaxed. 

Indications. — The  chief  indication  for  combined  or  bipolar  version  in 
its  complete  form  is  a  placenta  previa  in  which,  before  the  cervix  is  suffi- 
ciently dilated  to  admit  the  hand  it  is  desired  to  pull  down  one  leg  and 
thigh  to  serve  as  a  uterine  tamponade  to  control  hemorrhage. 

Technic. — AVith  the  patient  in  the  lithotomy  position  under  anes- 
thesia, with  the  bowels  and  bladder  empty  and  the  vulva  aseptically 


METHODS  OF   VERSION 


771 


prepared,  the  sterile  gloved  hand,  folded  in  cone  shape,  is  gently  passed 
between  the  separated  labia  into  the  vagina  as  far  as  the  cervix.  Two 
fingers  of  this  hand  are  then  passed  through  the  cervix  and  work  on  the 
lower  portion  of  the  fetus  while  the  other  hand  on  the  abdomen  works 
on  the  upper  portion  (see  Fig.  465).  If  it  is  a  podalic  version  which  is 
desired,  as  is  usually  the  case  in  a  placenta  previa,  the  steps  of  the  opera- 
tion mav  be  outlined  as  follows : 


Fig.  463. — External  version  in  a  transverse  presentation.     Obstetrician  above  the  pelvis. 

1.  Displacement  of  the  presenting  part  which  is  undesired. 

2.  Downward  pressure  upon  the  part  desired  in  the  pelvis,  i.  e.,  one 
of  the  lower  extremities. 

3.  Rupture  of  the  membranes. 

4.  Traction  on  the  lower  extremity  from  within  while  elevation  of  the 
head  is  assisted  by  the  other  hand  from  without. 

The  above  might  be  called  a  typical  complete  version  by  the  com- 
bined or  bipolar  method.  It  is  also  frequently  indicated  in  transverse 
cases  in  which  it  is  not  necessary  to  go  far  to  reach  and  bring  down  the 


VERSION 


part  desired.  In  eiddition  to  this  the  obstetrician  often  makes  use  of  a 
method  which  might  be  called  a  partial  version  })y  the  combined  or 
bipolar  method;  /.  e.,  with  one  hand  in  the  vagina  and  two  fingers  in 
the  cervical  canal,  while  the  other  hand  works  through  the  abdominal 
wall,  he  changes  the  position  of  the  presenting  part  so  as  to  facilitate 
delivery.  As  instances  of  this  may  be  mentioned  the  partial  rotation 
of  the.  head  from  an  occipitoposterior  to  an  occipito-anterior  position; 
the  flexing  of  a  poorly  flexed  head,  etc. 


Fig.  464. — External  version  in  a  transverse  presentation.    Obstetrician  below  the  pelvis. 

Advantages  of  Combined  Version. — 1.  It  can  be  performed  before  the 
cervix  is  sufficiently  dilated  to  allow  of  the  passage  of  the  hand. 

2.  If  strict  asepsis  and  reasonable  care  observed  the  operation  carries 
with  it  scarcely  any  danger  to  either  mother  or  child. 

Disadvantages. — The  chief  disadvantage  lies  in  the  fact  that  two  fingers 
working  in  the  cervical  canal  have  but  a  limited  control  over  the  fetal 
parts  which  come  within  reach. 


METHODS  OF   VERSION 


773 


Internal  Version. — In  this  method  the  whole  hand  is  passed  into  the 
uterine  cavity  (see  Fig.  466)  and  works  on  the  part  desired  while  the 
other  hand  assists  externally  through  the  abdominal  wall.  In  internal 
version  the  part  desired  to  be  brought  down  through  the  cervical  canal 
is  usually  a  foot,  hence  internal  version  is  usually  synonymous  with 
podalic  version.  Podalic  version  is  frequently  performed  in  placenta 
previa  by  the  combined  method,  but  this  is  about  the  only  condition 
in  which  the  podalic  version  is  not  postponed  until  the  cervix  is  suffi- 
ciently dilated  to  admit  the  hand.  Even  in  placenta  previa  it  is  the 
author's  custom  to  perform  internal  podalic  version  after  mechanical 
dilatation  with  the  elastic  bag  rather  than  version  by  the  combined 
method. 


Fig.  465. — Combined  or  bipolar  version. 

Conditions. — The  conditions  under  which  an  internal  version  is  a 
suitable  procedure  are  extremely  important  to  recognize.  They  are  as 
follows:   . 

1.  The  cervix  must  be  dilated,  or  dilatable  enough  to  allow  of  the 
passage  of  the  obstetrician's  hand. 

2.  The  uterus  must  not  be  so  firmly  contracted  as  to  make  rupture 
liable. 

The  last  condition  will  be  emphasized  when  discussing  the  contra- 
indications to  version. 

Technic. — The  first  step  is  to  determine  as  far  as  possible  by  external 
palpation  the  exact  presentation  and  position  of  the  fetus.    The  patient 


774 


VERSION 


should  then  bo  anesthetized  and  catheterized  if  she  has  not  recently 
emptied  her  bhidder.  She  should  be  placed  in  the  lithotomy  position 
with  vulva  shaved,  disinfected  and  surrounded  with  sterile  drapery. 
The  liands  and  forearms  of  the  obstetrician  should  be  carefully  scrubbed 
and  disinfected  and,  of  course,  sterile  gloves  should  be  worn. 
Two  (piestions  now  present  themselves: 

1.  ^Yhich  hand  shall  be  introduced? 

2.  Which  foot  shall  be  brought  down? 

The  hand  introduced  should  be  that  whose  palm  naturally  comes  in 
apposition  to  the  abdomen  of  the  fetus.    Thus,  in  a  vertex  presenta- 


FiG.  466. — Internal  version. 


tion,  if  the  fetal  back  lies  to  the  left,  the  left  hand  of  the  obstetrician 
should  be  introduced,  and  vice  versa. 

The  anterior  foot,  i.  e.,  the  one  lying  nearest  to  the  anterior  uterine 
wall,  should  be  first  brought  down  for  several  reasons: 

1.  It  is  usually  a  simpler  mechanism,  and  the  version  is  more  apt  to 
occur  in  one  plane. 

2.  It  is  more  apt  to  bring  the  fetal  back  to  the  front. 

3.  Being  a  simpler  mechanism,  it  is  less  apt  to  displace  the  arms  to 
the  back  of  the  neck. 

Having  selected  the  hand  to  be  introduced,  the  obstetrician  folds  it 
in  conical  shape  and  passes  it  gently  into  the  vagina  ])etween  the  labia 


METHODS  OF  VERSION  775 

which  are  carefully  separated  by  the  fingers  of  the  other  hand.  Having 
reached  the  cervix,  if  this  is  not  sufficiently  dilated  to  allow  of  the  pas- 
sage of  the  closed  fist,  the  cervical  canal  should  be  gently  dilated  until 
the  closed  fist  will  easily  pass  up  and  down  through  it.  It  must  be  remem- 
bered that  it  is  the  after-coming  head  which  is  likely  to  cause  most  diffi- 
culty in  delivery,  hence  a  complete  dilatation  of  the  cervix  is  desired. 
In  this  connection  it  may  be  mentioned  that  it  is  of  advantage  that 
each  obstetrician  should  compare  the  size  of  his  closed  fist  with  that 
of  the  fetal  head,  so  that  he  may  estimate  the  amount  of  dilatation 
when  his  fist  will  pass  through  the  cervical  canal.  If  the  membranes 
are  unruptured  and  no  loops  of  cord  are  felt  in  the  lower  uterine  segment, 
they  may  be  ruptured  soon  after  passing  the  cervix.  If  loops  of  cord 
are  felt,  it  is  well  to  go  higher  before  rupturing  the  membranes.  As  a 
rule  only  one  foot  should  be  seized,  and  this  by  inserting  the  thumb  over 
the  instep  with  the  forefinger  just  above  the  heel.  The  characteristics 
of  a  foot  as  compared  to  a  hand  have  already  been  mentioned  (see  page 
297).  If  a  uterine  contraction  comes  on,  no  attempt  at  version  should 
be  made  until  the  contraction  passes  off.  During  a  period  of  uterine 
relaxation  the  seized  foot  may  be  brought  down  through  the  cervical 
canal,  while  the  other  hand  of  the  obstetrician  from  without  the  abdomen 
lifts  up  the  head  and  favors  the  version.  The  half-breech  as  it  comes 
through  the  cervix  still  further  dilates  it  and  prepares  the  way  for  the 
after-coming  head.  After  the  half-breech  has  passed  the  vulvar  outlet 
and  the  other  foot  has  been  delivered,  the  further  conduct  of  the  case  is 
that  of  ordinary  breech  extraction  (see  page  711). 

In  a  transverse  or  shoulder  presentation,  not  infrequently  an  arm 
is  found  prolapsed  through  the  cervix  into  the  vagina.  Under  such  cir- 
cumstances it  is  sometimes  an  advantage  to  put  a  sterile  bandage  as  a 
fillet  around  the  wrist  of  the  prolapsed  arm  and  have  it  loosely  held  by 
an.  assistant  during  the  version,  so  that  extension  of  the  arm  by  the  side 
of  the  head  or  behind  the  neck  will  be  avoided. 

In  transverse  presentations  the  seizure  of  the  anterior  foot,  i.  e.,  the 
one  nearer  the  anterior  uterine  wall,  is  the  method  of  choice. 

Contra-indications. — One  of  the  most  important  phases  of  internal 
podalic  version  is  its  contra-indications.  A  neglect  of  these  has  cost  the 
life  of  many  a  woman  from  rupture  of  the  uterus,  hence  the  necessity  of 
their  careful  consideration. 

Internal  podalic  version  is  contra-indicated: 

1.  When  the  uterus  is  in  tonic  contraction,  i.  e.,  when  the  liquor 
amnii  is  drained  away  and  the  uterus  is  contracted  on  the  child,  with 
little  relaxation.  In  this  condition  the  lower  uterine  segment  is  usually 
thinned  out;  the  upper  segment  is  elevated,  and  the  lower  segment  will 
not  endure  without  rupture  the  additional  tension  incident  to  the  version. 

2.  When  the  pelvis  is  too  small  for  the  delivery  of  a  breech  presen- 
tation. In  general  it  may  be  stated  that  a  true  conjugate  of  less  than 
8  cm.  is  too  small  for  the  safe  delivery  of  the  after-coming  head  of  a 
full-sized  child,  hence  with  a  pelvis  of  this  size  internal  podalic  version 
should  not  be  attempted. 


CHAPTER  XXVII. 
DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL. 

SYMPHYSEOTOMY   AND    PUBIOTOMY. 

For  many  years  it  has  been  known  that  on  account  of  the  mobility 
at  the  sacro-iliac  joints  and  the  fact  that  these  joints  converge  from 
above  downward,  if  the  anterior  pelvic  wall  is  divided,  the  end  of  the 
innominate  bones  will  swing  downward  and  outward,  enlarging  the 
pelvic  canal.  The  enlargement  is  greater  in  the  transverse  and  oblique 
diameters  than  it  is  in  the  anteroposterior,  although  the  space  is 
increased  by  the  gap  between  the  ends  of  the  pubic  bones. 

There  have  been  in  use  in  obstetrics  two  methods  of  division  of  the 
anterior  pelvic  wall  for  enlarging  the  parturient  canal.  In  one  the 
division  has  been  made  through  the  joint  at  the  symphysis  (see  Fig.  467) 


Fig.  467. — Division  of  the  anterior  pelvic  wall  in  symphyseotomy  and  pubiotomy. 

and  is  called  symphyseotomy;  in  the  other  the  division  has  been  made 
through  the  pubic  bone  itself,  usually  the  left,  and  is  called  pubiotomy. 
As  symphyseotomy  was  first  introduced,  it  will  be  first  considered. 

Symphyseotomy. — This  operation  was  first  performed  on  a  living  sub- 
ject by  Sigault,^  in  1777,  who  succeeded  by  it  in  delivering  a  woman  with 
a  rachitic  pelvis,  of  a  living  child  after  four  successive  stillbirths.  The 
mother  survived,  although  she  had  a  permanent  urinary  fistula,  and  had 
difficulty  in  walking.  Although  for  a  time  the  operation  was  performed 
with  considerable  enthusiasm,  the  complications  were  found  to  be  so 
numerous  and  the  mortality  so  high  that  it  soon  fell  into  disfavor.    In 

'  Discours  sur  les  avantages  de  la  section  de  la  symphyse  dans  les  acconchemens,  etc., 
Paris,  1779. 

( 776 ) 


SYMPHYSEOTOMY  AND  PUBIOTOMY  777 

1866  the  operation  was  revived  by  Morisani,  of  Naples,  who  was  able 
to  reduce  the  mortality  to  20  per  cent.  Spinelli,  in  1891,  reintroduced 
the  operation  in  France  and  it  soon  became  a  popular  operation  with 
Pinard  at  the  Baudelocque  Clinic.  The  first  operation  in  this  country 
was  performed  by  Jewett,  in  1892,  and  during  the  succeeding  five  years 
nearly  every  obstetrician  with  a  hospital  service  performed  a  few  opera- 
tions. The  operation,  however,  on  account  of  the  uncertainty  of  obtain- 
ing a  living  child,  the  tedious  convalescence,  perhaps  permanent 
disability  of  the  mother,  and  its  high  mortality,  gradually  fell  into  disuse 
and  is  now  practically  obsolete. 

Technic. — In  general  there  have  been  three  methods  of  operating: 

1.  The  Italian  or  suprapubic  method. 

2.  The  French  or  open  method. 

3.  The  American  or  Ayer's  method. 

The  Italian  or  Suprapuhic  MetJwd. — In  this  method,  which  was  the 
one  followed  by  jNIorisani,  a  short  incision  is  made  in  the  median  line 
just  above  the  pubis,  sufficiently  large  to  admit  the  index-finger  between 
the  symphysis  and  the  peritoneum.  The  peritoneum  and  bladder  are 
pushed  away  from  the  sjTuphysis  and  along  the  finger  thus  introduced 
a  blunt-pointed,  curved  knife  is  passed  and  the  symphysis  divided  from 
behind  forward  and  from  below  upward.  The  original  knife  w^as  quite 
a  heavy  instrument,  and  was  called  a  Galbiati  knife,  although  subse- 
quently a  blunt-pointed,  curved  bistoury  was  often  used. 

The  French  or  Open  Method.  —  In  this  method,  which  was  the  one 
followed  by  Pinard  at  the  Baudelocque  Clinic,  an  incision  is  made  along 
the  front  of  the  symphysis  and  the  joint  divided  from  before  backward 
under  direct  inspection.  The  incision  begins  just  above  the  symphysis 
and  stops  just  above  the  clitoris,  which  is  pulled  a  little  to  one  side  to 
avoid  wounding  it. 

The  American  Subcutaneous  or  Ayer's^  Method.  —  In  this  a  small 
incision  is  made  a  little  above  the  subpubic  arch,  and  under  the  elevated 
clitoris  a  narrow  tenotomy  knife  is  passed  with  the  point  close  to  the 
joint  up  to  within  one-half  inch  of  the  top,  separating  the  overlying 
soft  tissues  from  the  joint;  a  probe-pointed  bistoury  is  substituted 
for  the  tenotomy  knife,  and  under  the  guidance  of  a  finger  in  the  vagina 
the  symphysis  is  divided  from  above  downward  and  from  before  back- 
ward. 

In  all  these  methods  of  operating  it  is  customary  to  catheterize  the 
bladder  and  with  the  catheter  to  hold  the  urethra  to  one  side  while 
dividing  the  symphysis. 

Result  of  Dividing  the  Symphysis. — It  is  often  found  that  even  after 
the  division  of  the  sjrtnphysis  the  pubic  bones  are  held  in  apposition  by 
the  strong  subpubic  ligament.  When  this  is  divided,  however,  the 
ends  of  the  bones  separate  from  3  to  6  cm.  If  this  separation  is  allowed 
to  exceed  6  cm.  it  is  usually  found  that  the  sacro-iliac  joints  are  strained 
and  may  cause  distressing  sjTiiptoms  afterward.    It  is  generally  regarded 

1  Amer.  Jour.  Obst.,  July,  1897,  xxxvi,  1-15. 


778  DELIVERY  BY   METHOD!^  DISTINCTLY  SVBCICAL 

that  a  st>i)arati()n  of  0  cm.  at  the  symphysis  increases  the  conjugate 
diameter  of  the  pelvis  about  12  mm.,  the  other  diameters  of  the  pelvis 
being  correspondingly  increased.  In  order  to  prevent  the  separation 
of  the  pubic  bones  beyond  the  safe  limit  of  6  cm.,  the  trochanters  during 
the  operation  should  be  supported  by  an  assistant  on  each  side  of  the 
patient. 

In  a  few  instances  the  symphysis  is  found  so  calcified  that  the  division 
has  to  be  made  with  a  chain-saw  rather  than  with  a  bistoury. 

Steps  of  the  Operation. — After  thorough  aseptic  preparation  of  the  field 
of  operation,  the  symphysis  is  divided  by  one  of  the  methods  already 
described.  The  author  in  his  operations  usually  preferred  the  Italian 
method.  After  the  division  of  the  symphysis  and  while  the  trochanters 
are  still  supported  by  assistants,  the  child  should  be  delivered  by  forceps 
or  version,  although  some  obstetricians  have  advocated  leaving  the 
case  to  nature  after  division  of  the  symphysis.  After  delivery  of  the 
child  and  expulsion  of  the  placenta  the  ends  of  the  pubic  bones  are 
approximated,  great  care  being  taken  that  the  bladder  is  not  caught 
between  the  ends  of  the  bones.  The  soft  parts  over  the  joint  are  sutured ; 
a  sterile  dressing  is  applied,  and  over  this  dressing  broad  strips  of  rubber 
adhesive  plaster,  extending  around  the  pelvis.  In  order  to  supplement 
the  action  of  the  adhesive  straps  in  holding  the  pubic  bones  in  apposition 
it  has  been  customary  to  keep  the  patient  in  a  hammock-bed  or  a  Brad- 
ford frame  for  about  three  weeks. 

Indications. — For  a  time  the  indications  for  s\'mphyseotomy  were 
thought  to  be  furnished  by  those  contractions  of  the  pelvis  which  are 
now  regarded  as  relative  indications  for  Cesarean  section,  i.  e.,  conju- 
gate diameters  varying  from  9  cm.  to  7  cm.  At  the  present  day,  however, 
s^Tnphyseotomy  is  scarcely  ever  performed,  either  a  Cesarean  section 
or  rarely  a  pubiotomy  being  preferred. 

Prognosis. — The  great  drawbacks  to  the  operation  of  symphyseotomy 
are  its  high  maternal  mortality  and  morbidity  and  its  high  fetal  mor- 
tality. In  spite  of  all  care  the  position  of  the  wound,  the  close  approxi- 
mation of  the  thighs,  and  the  constrained  position  of  the  patient  make 
cleanliness  difficult  to  maintain  and  drainage  poor.  These  conditions 
readily  lead  to  infection  and  phlebitis  is  not  uncommon.  ^Moreover, 
vaginal  tears  and  tears  extending  into  the  bladder  are  relatively  frequent. 
The  convalescence  is  tedious  and  even  after  the  patient  is  out  of  bed 
the  mobility  at  the  symphysis  is  often  such  as  to  cause  a  waddling  gait 
for  several  months.  The  union  at  the  symphysis  after  symphyseotomy 
is  fibrous  rather  than  bony,  and  this  occasionally  leads  to  a  slight  per- 
manent enlargement  of  the  pelvis  favorable  for  subsequent  deliveries, 
but  often  associated  with  a  mobility  which  causes  fatigue  on  severe 
exertion.  A  great  drawback  to  the  operation,  aside  from  the  high 
maternal  morbidity  and  mortality  is  the  difficulty  in  determining  whether 
a  living  child  can  be  extracted  after  the  operation  and  the  high  fetal 
mortality  resulting.  At  the  International  Congress  in  Amsterdam  in 
1899,  Barnes  presented  statistics  giving  the  maternal  mortality  of 
symphyseotomy  as  10.8  per  cent.,  and  the  fetal  mortality  as  14. ."i  per 


PUBIOTOMY 


779 


cent.    Although  these  percentages  have  more  recently  been  lowered  by 
individual  operators,  the  operation  is  not  one  to  be  recommended. 

Pubiotomy. — In  this  operation,  which  is  called  also  hebosteotomy, 
the  anterior  wall  of  the  pelvis  is  divided  by  an  incision,  not  through  the 
symphysis,  but  through  one  of  the  pubic  bones,  usually  the  left,  at  a 
little  distance  from  the  symphysis.  The  advantages  claimed  for  pubi- 
otomy over  symphyseotomy  are : 

1.  That  the  incision  being  through  bone  rather  than  cartilage,  will 
heal  more  readily  and  with  less  risk  of  infection. 

2.  That  the  lateral  incision  does  not  deprive  the  urethra  and  bladder 
of  their  natural  supports  as  does  the  median  operation. 


Fig.  468. — Pubiotomy,  showing  incision  made  and  needle  passed. 

These  arguments  were  strongly  presented  by  Gigli,^  in  1894,  and  he 
invented  the  flexible  saw  which  bears  his  name  and  by  which  most  of 
these  operations  are  performed.  -  Although  the  operation  was  suggested 
by  Gigli,  it  was  performed  by  Bonard,  Calderini,  Van  de  Velde  and  others 
before  him.  Furthermore,  the  open  operation  of  Gigli  was  soon 
improved  by  Doderlein  and  Bumm,  who  in  1904  and  1906  respectively, 
made  the  operation  more  or  less  subcutaneous.  Doderlein's  method 
consists  in  making  a  short  transverse  incision  just  above  the  upper 
margin  of  the  pubic  bone,  extending  about  2.5  cm.  inward  from  the 
pubic  spine.  A  finger  is  then  passed  in  separating  the  tissues  from  the 
posterior  surface  of  the  bone  (see  Fig.  468)  and  along  the  finger  a  strong 
needle,  resembling  an  aneurysm  needle,  is  passed  until  the  lower  edge 

'  Taglio  lateralizzato  del  pube,  sua  vantaggi,  sua  tecnica,  Ann.  di  os.  e  gin,  1894,  No.  10. 


780 


DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 


of  the  how  is  reached.  It  is  then  curxed  sharply  forward  and  over  its 
projecting  {)oint  in  the  hibium  niajus  a  small  incision  is  made.  The 
point  of  the  needle  is  then  made  to  emerge  and  into  its  eye  is  hooked  the 
end  of  the  flexible  saw  which  is  withdrawn  with  the  needle  through  the 
upper  opening.  The  upper  handle  is  then  attached  and  (see  Fig.  469) 
the  saw  is  ready  for  work.  In  using  the  saw  care  should  be  taken  to 
keep  the  line  of  the  saw  between  the  two  handles  as  straight  as  possible, 
as  in  this  way  the  saw  is  less  likely  to  break.  The  sawing  should  be  con- 
tinued until  the  bone  is  completely  severed  and  the  saw  moves  freely 
beneath  the  skin.  As  the  saw  is  withdrawn  there  is  usually  quite  free 
bleeding,  but  this,  as  a  rule,  soon  ceases  on  gauze  pressure.  As  soon  as 
the  bone  is  severed  a  slight  gaping  occurs  and  as  traction  is  made  on  the 
child  the  separation  of  the  ends  of  the  bones  increases.  As  in  symphyse- 
otomy, 6  cm.  should  be  considered  the  limit  of  safe  separation  and  any 


Fig.  469. — Pubiotoniy.     Flexible  saw  in  place. 


further  separation  should  be  avoided  by  pressure  upon  the  trochanters 
by  assistants. 

In  Bumm's  method  the  operation  is  made  still  more  subcutaneous: 
The  needle  is  made  to  enter  the  upper  part  of  the  labium  majus,  is  carried 
up  behind  the  pubic  bone,  under  the  guidance  of  a  finger  in  the  vagina, 
and  is  made  to  emerge  through  the  skin  just  above  the  upper  margin 
of  the  pubic  bone,  between  the  spine  and  the  symphysis.  The  saw  is 
then  hooked  into  the  eye  of  the  needle  and  drawn  into  place  from  above 
downward.  The  strongest  advocate  of  pubiotomy  in  this  country  has 
been  Professor  J.  Whitridge  Williams,  of  Johns  Hopkins  University, 
and  his  results  have  certainly  been  brilliant.  Up  to  January,  1912, 
he,  together  with  his  assistants  had  performed  38  successful  pubiotomies 
upon  36  patients,  2  women  having  been  operated  on  twice.  The  method 
followed  by  Williams  has  been  that  of  Doderlein  (see  Figs.  468  and  469) 


PUBIOTOMY  781 

and  is  the  one  usually  followed  in  this  country.  As  in  symphyseotomy  a 
long  strip  of  rubber  plaster  is  passed  around  the  pelvis  over  the  sterile 
dressing  and  the  patient  is  kept  in  a  Bradford  frame  for  two  weeks. 
Williams  allows  his  patients  to  try  to  walk  on  the  second  or  third  day 
after  getting  up. 

Indications  and  Contra-indications. — The  indication  for  pubiotomy, 
like  that  for  s\TQphyseotomy,  is  a  moderate  disproportion  between  head 
and  pelvis,  with  mother  and  fetus  in  good  condition,  as  for  instance,  in 
a  simple  flat  pelvis  a  conjugate  varying  from  7  to  8.5  cm.,  and  in  a 
justominor  flat,  a  conjugate  varying  from  7.5  to  9  cm.,  depending  upon 
the  size  of  the  fetal  head.  Fully  as  important  as  the  indication  for 
pubiotomy  are  its  contra-indications: 

1.  Pubiotomy  should  not  be  selected  when  the  pelvis  is  too  small  to 
allow  of  the  passage  of  the  head  after  division  of  the  pubic  bone  and 
separation  of  the  ends  for  a  distance  of  6  cm.  This  is  naturally  difficult 
in  some  cases  to  determine. 

2.  Pubiotomy  should  not  be  done  when  the  mother  is  infected. 

3.  Pubiotomy  should  not  be  performed  when  the  vitality  of  the 
fetus  is  low  or  its  life  very  uncertain. 

The  second  and  third  contra-indications  to  pubiotomy  bring  the  opera- 
tion into  competition  with  abdominal  Cesarean  section.  When  first 
introduced,  it  was  thought  that  pubiotomy  might  find  a  field  when  the 
time  for  an  abdominal  Cesarean  section  had  passed,  as  when  the  woman 
had  been  in  labor  for  hours  and  perhaps  after  frequent  attempts  at 
delivery  and  maternal  infection  was  feared.  Most  operators  have 
reached  the  conclusion,  however,  that  under  these  circumstances  pubi- 
otomy is  contra-indicated  as  well  as  Cesarean  section. 

Prognosis. — In  the  hands  of  the  best  operators  the  maternal  mortality 
of  pubiotomy  has  been  reduced  below  2  per  cent. ;  thus,  Doderlein,  in 
1910,  collected  321  pubiotomies,  performed  in  seven  German  clinics 
■up  to  that  year,  with  a  mortality  of  only  5.8  per  cent.  The  lowest  fetal 
mortality  in  the  hands  of  the  best  operators  ranges  between  4  and  8 
per  cent.  This  brings  the  lowest  maternal  mortality  of  pubiotomy 
about  on  a  par  with  the  lowest  maternal  mortality  of  Cesarean  section, 
but  the  lowest  fetal  mortality,  4  to  8  per  cent.,  is  still  much  higher  than 
the  fetal  mortality  of  Cesarean  section,  which  is  practically  7iil  in  similar 
cases.  Moreover,  when  comparing  pubiotomy  with  Cesarean  section, 
the  common  complications  and  morbidity  must  be  considered  as  well 
as  the  mortality. 

Objections  to  Pubiotomy.- — The  hemorrhage  occurring  during  a  pubi- 
omy  is  usually  venous  and  easily  controlled  by  pressure,  but  at  times 
it  is  profuse,  and  may  be  difficult  to  check.  The  vaginal  tears,  even  after 
dilatation  of  the  cervix,  are  sometimes  quite  extensive  and  need  repair. 
Injuries  of  the  bladder,  either  by  direct  tear  or  from  pressure  and  necrosis, 
are  not  uncommon.  Thrombophlebitis  is  a  rather  common  complication 
of  the  convalescence.  The  above  complications  studied  in  connection 
with  the  uncertainty  of  securing  a  living  child  by  the  operation,  make 
one  hesitate  to  recommend  the  operation. 


782 


DELIVERY  BY   METHODS  DISTINCTLY  SURGICAL 


CERVICAL   INCISIONS    AND    VAGINAL   CESAREAN    SECTION. 

In  order  to  avoid  the  deep,  irregular  cervical  tears  which  are  apt 
to  follow  a  rapid  delivery  through  a  rigid,  undilated  cervix,  Diihrssen,^ 
in  1890,  recommended  that  deep  incisions  be  made  in  the  vaginal  portion 
of  the  cervix.  These  incisions  were  made  in  either  the  anterior  or  the 
posterior  halves  of  the  cervix,  or  both,  but  the  lateral  portions  were 
avoided.  They  were  carried  to  the  vaginal  junction  and  caused  an 
immediate  enlargement  of  the  cervical  canal.    They  were  sutured  after 


Fig.  470. — Lines  of  incision  in  anterior  vaginal  wall. 

the  completion  of  the  labor.  This  method  of  enlarging  the  canal  has  met 
with  little  favor  in  this  countr\',  as  it  was  soon  found  that  the  incisions 
did  not  reach  high  enough  to  remove  the  resistance  at  the  internal 
OS,  and  that  extensive  lacerations  which  were  often  difficult  to  suture 
were  apt  to  follow.  Furthermore,  hemorrhages  sometimes  occurred 
which  were  difficult  to  control.    For  these  reasons  most  obstetricians  in 


'  Uchor  (Ion  Werth  der  tiefen  Cervix  unci  Srheiden  Damn  M.M.  Einsehnitte  in  der  Geburt- 
shiilfe,  Archiv  f.  Gyn.,  1S90,  xxxvii.  27  66;  Transactions  of  the  American  Gynecological 
Society,  1906,  xxxi,  116-127;  Der  \'aginale  Kaiserschnitt,  Berlin,  1S96. 


CERVICAL  INCISIONS  AND   VAGINAL  CESAREAN  SECTION     783 

recent  years,  when  they  have  used  "Diihrssen's  incisions,"  have  Hmited 
their  employment  to  cases  in  which  the  cervix  has  become  obhterated, 
but  the  OS  has  continued  rigid.  Even  here  the  author  beheves  that 
gradual  dilatation,  either  with  the  fingers  or  with  an  elastic  bag,  is  prefer- 
able. However,  he  admits  that  a  clean  cut  is  preferable  to  a  ragged 
laceration,  and  in  rare  instances,  where  in  the  interest  of  either  mother 
or  child  it  is  necessary  to  hurry  the  delivery,  a  cervical  incision  may  be 
of  value.  In  these  instances  one  or  tM'o  incisions  will  often  answer  as 
well  as  more  and  time  is  saved  in  suturing. 


Fig.  471. — Separating  vaginal  flaps  from  uterus  and  bladder. 

Realizing  that  incision  of  the  vaginal  portion  of  the  cervix  did  not 
enlarge  the  canal  sufficiently  for  immediate  delivery,  Diihrssen  devised 
the  operation  which,  in  1895,  he  described  under  the  name  of  "anterior 
vaginal  hysterotomy,"  and  in  1896  called  vaginal  Cesarean  section. 

The  operation  consists  of  an  incision  through  the  cervix,  either  anteriorly 
or  both  anteriorly  and  posteriorly,  extending  high  enough  into  the  lower 
uterine  segment  to  furnish  a  sufficient  enlargement  of  the  uterine  canal 


784 


DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 


for  the  delivery  of  the  child.  This  operation  necessitates  a  separation 
of  the  bladder  and  the  anterior  fold  of  peritoneum  from  the  lower  uterine 
segment. 

Technic.  —  The  patient  is  placed  in  the  lithotomy  position;  the 
bladder  is  emptied;  the  vulva  is  shaved  and  it,  together  with  the  vagina, 
is  aseptically  prepared.  The  field  of  operation  is  aseptically  draped  as 
for  any  vaginal  or  perineal  operation.  Two  volsella  forceps  are  applied 
to  the  anterior  lip  of  the  cervix,  one  on  each  side  of  the  median  line,  and 


i»C5^*- 


Fig.  472. — Division  of  cervix  and  lower 
uterine  segment. 


Fig.  473. — Separation  of  uterine  incision, 
showing  bulging  membranes. 


the  cervix  is  brought  down  into  view^  (see  Fig.  470) .  An  inverted  T-shaped 
incision  is  made  in  the  anterior  vaginal  w^all,  the  horizontal  part  of  the 
incision  being  made  at  the  cervicovaginal  junction,  and  the  longitudinal 
incision  beginning  about  an  inch  posterior  to  the  meatus.  The  triangular 
vaginal  flaps  thus  outlined  are  then  separated  from  the  uterus  and  the 
bladder,  partly  by  dissection  and  partly  by  pressure  with  a  gauze  sponge 
(see  Fig.  471).  The  next  step  in  the  operation  is  to  separate  the  bladder 
from  the  uterus  and  to  raise  it  so  as  to  expose  the  lower  uterine  segment. 
This  separation  is  done  chiefly  by  pressure  with  a  gauze  sponge.    Then 


VAGIXAL   CESAREAN  SECTION 


785 


follows  a  division  of  the  lower  uterine  segment  in  the  median  line  (see 
Figs.  472  and  473).  If  sufficient  room  is  not  furnished  by  this  anterior 
incision  alone,  as  is  apt  to  be  the  case  after  the  eighth  month,  a  trans- 
verse incision  should  be  made  at  the  cervico vaginal  junction  posteriorly, 
and  the  rectimi  and  peritoneum  pushed  away  from  the  uterus.  The 
posterior  lip  of  the  cervix  is  then  divided  in  the  median  line  as  far  up 
as  may  be  necessary  (see  Figs.  474  and  475).  The  delivery  is  then 
accomplished  by  either  version  or  the  forceps,  the  former  being  usually 
the  preferable  operation.     If  the  posterior  incision  has  been  made,  it  is 


Fig.  474. — Division  of  posterior  lip  of  ceri,-is. 


usually  wise  to  suture  this  before  suturing  the  anterior  incision.  The 
incisions  in  the  uterus  are  sutured  before  those  of  the  vaginal  walls  (see 
Figs.  476  and  477).  Catgut  is  used  throughout  and  the  endometrium  is 
avoided. 

Indications. — The  chief  indication  for  vaginal  Cesarean  section  is  an 
eclampsia  in  which  the  cervix  is  long  and  rigid,  the  child  not  large, 
and  the  condition  of  the  mother  such  that  a  speedy  delivery  seems 
imperative,  i.  e.,  that  the  time  required  for  a  dilatation  by  means  of  an 
elastic  bag  would  greatly  endanger  the  welfare  of  the  mother  or  child, 
50 


rsG 


DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 


or  both.  In  yent'ral  the  indications  for  vaginal  Cesarean  section  may 
he  stated  as  conditions  in  which  a  speedy  delivery  is  urgently  demanded, 
and  in  which  the  obstacle  to  the  delivery  lies  solely  in  the  undilated 
cervix.  Thus  in  certain  cases  of  premature  separation  of  the  placenta, 
or  in  certain  cases  of  cardiac  disease,  etc.,  the  operation  has  a  valuable 
field  of  usefulness.  It  is  contra-indicated  in  a  contracted  pelvis  with 
dystocia  therefrom,  as  it  does  not  enlarge  the  bony  canal.     It  is  per- 


FiG.  475. — .Sepaiaticju  of  anterior  and  posturior  uterine  incisions,  sliowing  Ijulgiug 

membianes. 


formed  by  some  in  placenta  previa,  but  as  the  cervix  is  usually  soft  in 
this  condition,  the  author  prefers  either  dilatation  with  an  elastic  bag 
or  an  abdominal  Cesarean  section  to  the  vaginal  operation. 

Disadvantages. — The  operation  of  vaginal  Cesarean  section  must  not 
l)e  considered  a  simple  operation,  which  can  easily  be  performed  by  the 
general  practitioner  who  has  not  had  experience  in  vaginal  operations. 
It  may  be  a  difficult  operation.  The  cervix  may  not  readily  pull  down 
so  as  to  expose  the  lower  uterine  segment  (as  shown  in  Fig.  472).    This 


VAGINAL  CESAREAN  SECTION 


787 


may  require  making  the  upper  part  of  the  uterine  incision  by  the  sense 
of  touch  rather  than  sight.  During  the  dehvery  the  uterine  incision 
may  be  extended  by  tearing,  and  a  hemorrhage  occur  which  it  is  difficult 
to  check.  In  most  cases  the  uterus  after  dehvery  can  be  pulled  down 
so  that  with  suitable  retractors  the  upper  limit  of  the  incision  or  tear 
can  be  seen  and  sutured,  but  in  some  cases  this  is  not  easy.  Occasionally, 
in  spite  of  all  care,  the  bladder  is  injured  in  the  delivery  and  a  vesico- 
vaginal fistula  results.  The  author  believes  that  while  the  operation 
is  a  valuable  addition  to  our  different  methods  of  rapid  delivery,  it  is 


Fici.  476. — Suture  of  uterine  aud  ^•aginal 
incisions. 


Fig.  477. — Operation  conipk-tud. 


not  one  to  be  lightly  undertaken,  especially  by  a  novice.  For  a  full  de- 
scription of  the  operation  and  results  the  reader  is  referred  to  Diihrssen's 
article  in  Winckel's  Handbuch  der  Gehurtshillfe,  1905. 


CESAREAN    SECTION. 

The  operation  by  which  the  fetus  is  delivered  through  the  uterine 
and  abdominal  walls  by  an  incision  through  each  is  called  a  Cesarean 
section.. 


788  DELIVERY  BY   METHODS  DISTINCTLY  SURGICAL 

The  origin  of  this  term  has  been  surrounded  with  a  great  deal  of 
obscurity  and  been  the  subject  of  much  discussion.  Many  have  thought 
that  Juhus  Caesar  was  deHvered  in  this  way  and  that  the  operation 
derived  its  name  from  him.  Careful  investigation,  however,  has  found 
no  authority  for  this  view. 

Two  other  views  which  are  more  credible  are:  (1)  That  the  operation 
derived  its  name  in  some  way  from  the  Latin  verb  caedere,  to  cut,  or  (2) 
that  the  Roman  law,  requiring  the  abdomen  of  a  pregnant  woman 
dying  near  term  to  be  opened  and  the  child  removed,  enacted  under 
Xuma  Pompilius,  anfl  called  "lex  regia,"  came  to  be  called  under  the 
Caesars  or  other  emperors,  the  Cesarean  law.  It  would  then  be  an 
easv  step  to  transfer  the  name  Cesarean  from  the  law  to  the  operation 
itself. 

History. — Although  postmortem  Cesarean  section,  /.  e.,  removal  of 
the  child  through  the  uterine  and  abdominal  walls  of  a  woman  soon  after 
l^er  death,  had  undoubtedly  been  performed  many  times,  even  before 
the  Christian  era,  the  first  reported  attempt  to  perform  Cesarean  sec- 
tion on  a  living  woman  was  that  of  Jacob  Xufer,  a  Swiss  swinegelder, 
who,  in  1500,  successfully  operated  on  his  own  wife  after  the  midwives 
and  barbers  who  were  in  attendance  had  failed  to  deliver  her.  A  study 
of  the  details  of  this  case  seem  to  indicate  that  it  was  not  a  true  Cesarean 
section,  but  the  removal  from  the  abdomen  of  a  fetus  in  a  case  of  advanced 
ectopic  gestation.  The  first  authentic  case  of  the  Cesarean  section 
was  pr()ba]:)ly  that  of  Trautman,  of  \Vittenl)erg,  who  performed  the 
operation  in  1610.  After  this  the  operation  was  occasionally  done,  but 
always  with  a  high  mortality,  as  the  uterus  was  not  sutured  and  aseptic 
methods  were  unknown.  Even  as  late  as  1876  more  than  50  per  cent, 
of  the  women  died  from  hemorrhage  or  infection.  In  1876  a  distinct 
advance  was  made  and  the  mortality  of  the  operation  lowered  by  the 
suggestion  of  Porro,  who  recommended,  after  the  removal  of  the  child, 
constriction  of  the  cervix;  amputation  of  the  body  of  the  uterus  and 
stitching  the  cervical  stump  in  the  lower  angle  of  the  abdominal  wound. 
This  prevented  hemorrhage  and  the  leakage  of  lochia  into  the  abdominal 
cavity  and  lessened  the  risk  of  infection.  This  soon  became  the  popular 
method  of  performing  the  operation  and  held  its  own  until  1882,  when 
Sanger,  by  the  introduction  of  the  practise  of  suturing  the  incision  in 
the  uterus,  established  the  operation  on  a  permanent  basis. 

The  Sanger  method  of  suturing  and  leaving  the  body  of  the  uterus 
was  soon  found  to  have  so  many  advantages  over  the  Porro  operation, 
with  its  sloughing  stump  and  slow  healing,  that  the  Porro  operation  soon 
fell  into  disuse  save  in  cases  where  tumors  were  present  in  the  uterus. 
^^  ith  the  development  of  the  technic  of  supravaginal  hysterectomy 
for  fibromyomata,  in  which  dropping  the  cervical  stump  into  the  pelvic 
cavity  proved  to  be  the  best  procedure,  this  operation  soon  took  the 
place  of  the  Porro  operation  when  a  hysterectomy  was  indicated  in  the 
course  of  a  Cesarean  section 

^^  ith  the  improvement  in  surgical  technic,  asepsis  and  suture 
material,  the  mortalitv  of  Cesarean  section  toda^  in  clean  cases  is  less 


CESAREAN  SECTION  789 

than  3  per  cent.,  but  the  operation  itself  is  practically  that  recom- 
mended by  Sanger  in  1882. 

Indications. — The  indications  for  the  performance  of  Cesarean  section 
are  either  positive  or  relative. 

A  positive  indication  is  present  when  the  parturient  canal  for  any 
reason  is  so  narrowed  that  the  child  cannot  be  delivered  through  it  with 
safety  to  the  mother. 

A  relative  indication  exists  when,  even  if  the  child  could  be  delivered 
through  the  natural  passages.  Cesarean  section  offers  greater  safety  to 
both  mother  and  child. 

Positive  indications  are  most  often  presented  by  the  pelvis  itself, 
but  may  be  caused  by  tumors,  by  certain  fixed  malpositions  of  the 
uterus,  as  in  ventrofixation,  or  vaginal  fixation,  etc.  x\s  far  as  the  pelvis 
itself  is  concerned,  a  full-term  child  of  average  size  cannot  be  delivered 
alive  through  a  pelvis  with  a  conjugate  diameter  of  less  than  7  cm.  Hence 
a  pelvis  of  7  cm.  or  less  in  its  conjugate  is  considered  a  positive  indication 
for  a  Cesarean  section.  As  a  dead  child  cannot  be  delivered  by  crani- 
otomy through  a  conjugate  of  less  than  5  cm.,  this  measurement  of  con- 
jugate is  considered  a  positive  indication  for  Cesarean  section,  even 
when  the  child  is  dead. 

A  transverse  diameter  of  7  cm.  at  the  pelvic  outlet  is  usually  regarded 
a  positive  indication  for  Cesarean  section,  but  this  depends  upon  the 
length  of  the  posterior  sagittal  diameter  (see  page  657)  and  a  transverse 
diameter  of  7  cm.  at  the  outlet  may  present  only  a  relative  indication 
for  the  operation. 

Relative  Indications. — The  mortality  and  morbidity  of  Cesarean  sec- 
tion have  been  so  reduced  in  recent  years  by  improvement  in  technic 
and  early  operation  that  many  conditions  which  years  ago  would  not 
have  been  thought  of  as  belonging  in  the  class  in  which  Cesarean  sec- 
tion would  be  justified,  are  now  considered  as  presenting  relative  indica- 
tions for  this  procedure. 

As  far  as  the  pelvis  is  concerned,  a  conjugate  of  8.5  cm.  in  a  simple 
flat  and  9  cm.  in  a  justominor  flat  pelvis  may  with  every  justice  present 
a  relative  indication  for  Cesarean  section.  On  the  other  hand,  a  pelvic 
canal  may  be  roomy  enough  for  the  birth  of  a  small  child  and  yet  present 
a  relative  indication  for  Cesarean  section  with  a  larger  child.  From 
this  it  occasionally  happens  that  a  woman  may  be  delivered  naturally 
or  with  the  aid  of  the  forceps  in  her  first  labor  and  yet  be  best  delivered 
by  Cesarean  section  in  her  second  labor,  when  the  child  is  larger. 

Occasionally  cases  of  eclampsia  with  a  long,  rigid  cervix  and  cases 
of  central  placenta  previa  with  rigid  cervix  and  profuse  hemorrhage 
present  relative  indications  for  Cesarean  section.  The  same  may  be 
said  of  certain  cases  of  accidental  hemorrhage  with  a  long,  rigid  cervix. 
In  the  author's  opinion,  however,  these  indications  in  eclampsia  and 
placenta  previa  are  very  exceptional  and,  as  a  rule,  he  prefers  to  dilate  the 
cervix  with  an  elastic  bag  and  deliver  through  the  natural  passages. 
It  should  always  be  remembered  when  considering"  the  indications  for 
Cesarean  section,  that  usually  the  uterine  cicatrix  is  not  as  strong  as  the 


700  DELIVERY  BY  METHODS  DISTIXCTLY  SVEGICAL 

uncut  uterine  wall,  and  tliat  if  a  woman  is  once  subjected  to  a  Cesarean 
section,  there  is  always  more  or  less  risk  of  thinning  of  the  uterine  cicatrix 
or  even  rupture  of  the  uterus  in  subsequent  labors,  if  they  are  at  all 
difficult  or  prolonged.  Hence,  if  a  woman  has  once  been  dehvered  by 
Cesarean  section,  it  is  usually,  though  not  ahvays,  wiser  to  follow  this 
procedure  in  subsequent  labors,  imless  they  are  very  easy. 

An  idea  of  the  relative  frequency  of  the  different  indications  for 
Cesarean  section  may  be  gained  by  the  following  list  of  indications  in 
a  series  of  150  Cesarean  sections  performed  by  the  author  at  the  Sloane 
HospitaL    The  operation  was  performed  on  account  of: 

Contracted  pelvis 116 

Fibromyomata 8 

Ventral  fixation 6 

Vaginal  fixation 2 

Dermoid  cyst 4 

Ovarian  cystadenoma 3 

Congenital  displaced  kidnej's  (.5  times  in  same  patient) 5 

Carcinoma  of  cervix "1 

Double  uterus,  one-half  obstructing 1 

Abnormally  large  child 1 

Weakened  walls  from  pre\nous  Cesarean  section 2 

Toxemia,  long  rigid  cervix 1 

150 

^Yhen  studying  the  relative  indications  for  Cesarean  section,  certain 
general  facts  must  be  considered.  There  are  naturally  many  border-line 
cases  in  which  before  labor  it  is  impossible  to  tell  whether  the  patient 
will  be  able  to  deliver  herself  unaided  or  by  the  use  of  the  forceps,  or 
not.  So  much  depends  upon  the  character  of  her  uterine  contractions 
and  upon  the  moldability  of  the  fetal  head,  that  nothing  but  the  test 
of  labor  will  determine  it.  Realizing  that  if  a  Cesarean  section  is  per- 
formed in  the  first  labor,  the  uterine  cicatrix  will  probably  be  a  source 
of  anxiety  in  each  subsequent  pregnancy  and  very  likely  another  Cesar- 
ean section  will  be  considered  advisable,  the  author  is  strongly  of  the 
opinion  that  in  all  border-line  cases  the  woman  in  her  first  pregnancy 
should  be  given  a  test  labor  of  several  hours  to  see  if  she  is  not  able  either 
to  deliver  herself  naturally,  or  at  least  to  bring  the  presenting  part  within 
the  range  of  a  median-  or  low-forceps  operation.  Every  obstetrician  has 
occasionally  met  with  surprises  in  this  direction,  and  even  after  pre- 
parations for  a  Cesarean  section,  the  operation  has  been  found  unneces- 
sary. In  spite  of  the  low  mortality  of  Cesarean  section  at  the  present 
day,  it  is  an  ordeal  more  or  less  dreaded  by  both  husliand  and  wife,  and 
if  it  can  once  be  demonstrated  that  natural  labor  is  possible,  a  great 
dread,  which  otherwise  would  shadow  each  pregnancy,  is  lifted  from  the 
family.  Hence  the  advantage  of  a  test  labor  of  moderate  length  to  deter- 
mine whether  or  not  Cesarean  section  is  really  necessary.  On  the  other 
hand,  as  will  be  seen  when  studying  the  mortality  of  the  operation, 
this  is  increased  by  a  long  labor,  by  rupture  of  the  membranes,  and  by 
frequent  examinations.  Hence,  if  a  Cesarean  section  is  likely  to  be  neces- 
sary, great  care  should  be  taken  in  the  test  labor  to  avoid  causes  of 
increased  mortality.     The  chief  object  sought  in  a  Cesarean  section 


CESAREAN  SECTION  791 

which  is  relatively  indicated,  is  a  living  cliikl  vith  the  least  danger  and 
damage  to  the  mother.  To  attain  this  end  both  mother  and  child  must 
be  in  good  condition  at  the  time  of  operation.  To  perform  a  Cesarean 
section  and  deliver  a  defective  child  or  one  whose  vitality  has  been  so 
reduced  by  the  prolonged  pressure  of  a  long  labor  or  so  injured  by 
attempts  at  forceps  delivery  that  it  survives  but  a  few  hours,  is  a  great 
disappointment  to  everybody.  On  the  other  hand,  to  deliver  by 
Cesarean  section  a  child  which  lives  while  the  mother  is  lost  from 
infection  because  the  operation  was  postponed  too  long  and  the  risks 
were  multiplied  by  repeated  examinations  and  long  labor  after  rupture 
of  the  membranes,  is  bad  obstetrics.  A  Cesarean  section  is  indicated 
only  when  mother  and  child  are  in  good  condition;  either  are,  or  can  be, 
placed  in  good  surroundings,  preferably  in  a  well-appointed  hospital, 
and  in  cases  in  which  examinations  have  been  few^  and  under  the  strictest 
aseptic  precautions.  If,  during  pregnancy,  it  has  been  determined  that 
a  Cesarean  section  is  indicated,  it  is  desirable  that  no  vaginal  examina- 
tions be  made  near  the  time  of  operation.  In  this  way  one  source  of 
infection  is  avoided. 

Time  of  Operation. — ^While  it  is  an  advantage,  on  account  of  drainage 
of  lochia,  to  have  the  cervix  dilated  at  the  time  of  the  operation,  it  is  not 
necessary  to  wait  for  the  onset  of  labor  in  setting  the  time  for  a  Cesarean 
section.  It  is  desirable  to  have  the  pregnancy  at  term  and  the  child  as 
vigorous  as  possible^  but  the  advantages  of  complete  preparations,  good 
light  and  assistants,  all  of  which  may  be  obtained  if  the  hour  for  the 
operation  is  elective,  more  than  outweigh  the  advantages  of  a  cervix 
dilated  by  labor,  which  may  begin  unexpectedly  and  demand  prepara- 
tions and  assistants  which  are  those  of  emergency.  If  there  has  been 
no  labor  and  the  cervical  canal  is  not  sufficiently  dilated  for  drainage, 
this  dilatation  may  be  accomplished  by  passing  the  finger  down  through 
the  cervix  from  above,  while  the  hand  is  in  the  uterus.  The  author 
has  been  impressed  with  the  fact  that  the  cervix  does  not  have  to  be  as 
much  dilated  as  he  formerly  supposed,  and  that  after  a  Cesarean  sec- 
tion the  lochia  often  seems  less  than  after  a  normal,  delivery  and  he  has 
explained  it  by  the  possibility  that  the  decidua  in  many  cases  is  more 
completely  wiped  off  with  the  gauze  sponges  used  in  the  course  of  a 
Cesarean  section  than  is  cast  off  in  a  normal  labor. 

Technic. — The  preparation  of  the  patient  and  the  selection  and 
preparation  of  instrmnents  should  be  the  same  as  for  any  abdominal 
hysterectomy.  While,  as  a  rule,  the  Sanger  operation,  in  which  the  uterus 
is  not  removed,  is  the  operation  of  choice,  the  decision  may  be  reached 
in  the  course  of  the  operation  that  the  interests  of  the  mother  are  best 
served  by  a  hysterectomy,  hence  one  should  be  prepared  for  it.  Aside 
from  the  operator  and  the  anesthetist,  three  assistants  are  needed :  One 
to  help  at  wound,  one  to  hand  instruments,  and  one  to  receive  and  care 
for  the  baby.  The  baby  is  more  or  less  anesthetized  by  the  anesthesia 
of  the  mother,  hence  the  anesthesia  should  be  skilfully  administered, 
and  the  mother  kept  under  its  influence  as  short  a  time  as  possible  before 
the  deliverv  of  the  child. 


792 


DELIVERY  BY  METHODS   DISTINCTLY  SURGICAL 


Tilt'  Iiiri.sloN. — 111  the  iiKMlern  Cesarean  section  the  incision,  hotii  in 
the  ah(h)iniiial  and  uterine  walls,  is  just  lon^'  enou^li  to  achnit  of  the 
(lehvery  of  tiie  fetal  head.  As  a  rule  10  cm.,  or  4  inches,  suffices;  the 
choice  of  the  site  of  the  incision  varies  somewhat  with  different  operators. 
Some  prefer  an  incision  entirely  above  the  umbilicus,  while  others  prefer 
one  whose  midpoint  is  opposite  the  umbilicus.  The  author  prefers  the 
latter  incision  for  several  reasons: 

1.  With  the  lower  incision  the  uterus  is  less  likely  to  slip  away  from 
the  abdominal  wound  as  the  child  is  extracted.     This  is  important,  as 

cleanliness  of  the  abdominal  cavity  is  se- 
cured by  keeping  the  uterus  in  close  appo- 
sition to  the  abdominal  wound. 

2.  If  the  Cesarean  section  is  to  be  com- 
pleted with  a  hysterectomy,  it  is  more 
easily  performed  through  the  lower  incision. 
8.  If,  on  account  of  previous  infection 
of  the  uterine  cavity,  infection  of  the 
uterine  wall  should  occur,  a  readier  exit 
for  pus  through  the  abdominal  wound  and 
an  easier  through-and-through  drainage  are 
secured  in  the  lower  incision  than  in  the 
higher. 

4.  The  incision  whose  midpoint  lies 
opposite  the  umbilicus  is  high  enough  to 
bring  the  uterine  incision  in  the  upper  or 
contractile  segment  of  the  uterus,  and  that 
is  what  is  sought. 

One  of  the  ad\'antages  claimed  by  the 
advocates  of  the  high  incision  is  that  there 
is  less  risk  in  it  of  adhesion  between  the 
uterus  and  the  abdominal  cicatrix.  In  the 
experience  of  the  author,  however,  whether 
the  incision  is  made  wholly  above  the 
umbilicus,  or  with  its  centre  opposite  the  umbilicus,  the  uterus  at  the 
end  of  a  week  is  found  well  below  the  abdominal  incision,  so  that  per- 
manent adhesion  of  the  uterus  to  the  abdominal  cicatrix  is  not  to  be 
feared. 

During  the  author's  earlier  work,  the  abdominal  incision  was  carried 
to  the  left  of  the  umbilicus,  but  on  account  of  the  usual  rotation  of  the 
uterus  from  left  to  right  forward,  and  the  tendency  of  the  uterine  incision 
to  approximate  the  left  uterine  cornu  and  tube,  he  has  made  it  a  rule 
during  recent  years  to  carry  the  incision  to  the  right  of  the  umbilicus 
(see  Fig.  478).  In  this  way  the  uterine  incision  has  been  brought  nearer 
the  median  line.  \Yith  the  short  incision  the  uterus  is  not  lifted  out  of 
the  abdomen  until  after  the  child  has  been  extracted  and  the  question 
naturally  arises,  How  shall  the  abdominal  cavity  be  protected  during 
the  extraction  of  the  child?  The  author  tried  w^alling  off  the  intestines 
and  protecting  the  peritoneal  cavity  with  pads  and  having  his  assistant 


Fig.  478. — Cesarean  section.     Site 
of  abdominal  incision. 


CESAREAN  SECTION  793 

with  hands  on  each  side  of  the  abdomen  keep  the  uterus  pressed  firmly 
against  the  abdominal  wall  from  the  first  stroke  of  the  knife  until,  follow- 
ing the  delivery  of  the  child,  the  uterus  is  lifted  out  of  the  abdomen. 
This  latter  method  has  given  the  author  the  most  satisfaction  and  is  the 
method  he  has  followed  for  several  years.  The  pads  are  apt  to  become 
displaced  as  the  uterus  is  emptied,  and  have  seemed  not  only  to  have 
given  less  protection  to  the  peritoneal  cavity  than  the  other  method, 
but  to  have  favored  subsequent  adhesions. 

Hoiv  Shall  Uterine  Bleeding  be  Controlledf — For  a  time  it  was  thought 
necessary  to  have  an  assistant  firmly  hold  each  broad  ligament,  thus 
compressing  the  ovarian  and  uterine  arteries.  This  method  has  long 
been  abandoned  in  favor  of  stimulation  of  uterine  contraction  by  gentle 
manipulation  of  the  fundus  with  the  hand,  by  pouring  over  the  uterus 
hot  saline  solution  and  by  the  hypodermic  injection  of  aseptic  ergot. 
Recently  there  has  been  a  tendency  to  substitute  pituitary  extract  for 
ergot.  Every  Cesarean  section  operator  becomes  impressed  with  the 
fact  that  uteri  which  show  a  tendency  to  relax  and  bleed  when  held 
outside  of  the  abdomen,  contract  well  and  cease  bleeding  when  sutured 
and  replaced  within  the  abdominal  cavity.  Hence  too  much  time  should 
not  be  spent  in  endeavoring  to  make  the  uterus  contract  outside  of  the 
abdomen,  but  either  the  suturing  should  be  pushed  and  the  organ  replaced, 
or  if  the  tendency  to  relax  is  too  great,  the  uterus  should  be  replaced  and 
sutured  in  situ. 

Shall  gauze  be  left  in  the  uterus  with  end  leading  into  the  vagina,  for 
the  purpose  of  favoring  uterine  contraction  and  drainage?  In  the 
author's  earlier  cases  gauze  was  emploj'ed,  but  in  his  last  100  cases  it 
has  been  used  only  five  times.  It  was  found  to  be  unnecessary,  and  from 
the  difficulty  experienced  in  keeping  it  in  place  while  suturing  it  proved 
to  be  annoying. 

Material  and  Method  of  Suture. — Catgut  has  been  the  only  suture 
material  employed  in  either  the  uterine  or  the  abdominal  wound  in  all 
save  the  first  half-dozen  of  the  author's  cases. 

The  uterus  is  sutured  Avith  three  tiers  of  continuous  plain  catgut 
suture;  one  approximating  the  middle  muscular  layer,  one  passing 
through  peritoneal  coat  and  outer  half  of  muscle  wall,  and  one  closing 
the  peritoneum  over  the  previous  sutures  (see  Figs.  479,  480,  and 
481). 

The  abdominal  wall  is  sutured' with  three,  sometimes  four,  tiers  of 
continuous  catgut  sutures : 

1.  The  peritoneum  is  closed  with  plain  catgut. 

2.  The  fascia  is  approximated  with  chromicized  catgut. 

3.  The  fat,  if  abundant,  with  plain  catgut. 

4.  The  skin  with  subcuticular  suture  of  plain  catgut. 

Duration  of  the  Operation. — In  the  author's  series  of  150  Cesarean 
sections  the  average  time  from  the  first  cut  till  the  delivery  of  the  child 
was  38  seconds.  The  longest  delivery  consumed  3  minutes;  the  shortest 
delivery  consumed  9  seconds;  35  were  delivered  in  20  seconds  or  less. 
In  the  150  cases,  including  17  hysterectomies,  the  average  time  of  the 


794 


DELIVERY  BY  METHODS   DISTINCTLY  SURGICAL 


coinpk'lcd  operation  was  '1>>\  iiiiimtcs.     'I'lir  longest  operation  was  com- 
pleted by  hysterectomy,  coiisimiiii<!;  (12  mimites. 

Tlie  shortest  Sanger  Cesarean  section  consumed  14:^  minutes  in  its 
completion.  44ie  shortest  Cesarean  section  coni])leted  hy  hysterectomy 
consumed  '.V.\  minutes.  Tliere  were  S;]  Sanger  Cesarean  sections  which 
consumed  not  more  than  oO  mhuites  in  the  completion  of  the  operation. 


Fig.  479 


Fig.  480 


Fig.  481 


Figs.  479,  480,  and  481. — Steps  in  suturing  the  uterine  incision. 

The  question  is  often  asked,  What  is  the  advantage  of  a  quick  opera- 
tion in  the  performance  of  a  Cesarean  section?  Why  is  a  14f  minutes 
completed  operation  better  than  one  consuming  an  hour?  All  surgeons 
realize  that  any  operation  in  which  careful  technic  is  sacrificed  to  time 
is  faulty  in  the  extreme.  However,  in  a  Cesarean  section,  a  careful 
technic  coupled  with  a  short  time,  is  preferable  to  a  careful  technic 
coupled  with  a  long  time  for  these  reasons:  From  the  first  cut  in  the 
uterus  until  the  uterine  incision  is  closed  and  the  uterus  replaced  in  the 


CESAREAN  SECTION  795 

abdominal  cavity,  the  woman  is  losing  blood  from  the  nterine  sinnses. 
The  loss  of  blood  means  lessened  resistance  to  infection  and  a  slo^^'e^ 
convalescence.  Hence,  if  performed  with  the  same  care,  a  short  Cesarean 
section  is  better  for  the  w^oman  than  a  long  one. 

Subsequent  Care. — The  subsequent  care  of  a  patient  upon  whom  a 
Cesarean  section  has  been  performed  is  smiilar  to  that  of  any  abdominal 
section.  By  the  third  day  the  baby  may  be  applied  to  the  mother's 
breasts  regularly  and  nursing  be  continued  thereafter.  The  author's 
custom  has  been  to  keep  the  patient  in  bed  for  two  weeks  and  allow  her 
to  leave  the  hospital  in  about  three  weeks. 

Mortality. — The  paramount  question  in  every  procedure  for  the 
delivery  of  a  pregnant  woman  is  the  maternal  mortality.  In  the  series 
of  150  Cesarean  sections  performed  by  the  author  there  were  10  maternal 
deaths,  or  a  maternal  mortality  of  6.66  per  cent. 

It  must  be  remembered,  however,  that  this  series  included  all  kinds 
of  cases  as  they  were  brought  to  the  hospital,  some  already  infected. 
Among  this  series  there  were  143  clean  non-toxic  cases,  and  among  these 
the  mortality  was  2.09  per  cent.  In  the  last  40  cases  of  the  series  there 
were  no  deaths.  As  experience  with  Cesarean  section  has  widened,  it 
has  become  well  established  that  the  maternal  mortality  increases  with 
the  number  of  hours  the  woman  has  been  in  labor,  the  number  of  hours 
her  membranes  have  been  ruptured,  and  with  the  number  of  vaginal 
examinations.  With  membranes  unruptured,  or  only  recently  ruptured, 
and  only  one  vaginal  examination,  and  that  under  strict  aseptic  precau- 
tions, the  maternal  mortality  should  be  less  than  3  per  cent. 

If  the  woman  has  been  in  labor  with  ruptured  membranes  for  many 
hours  and  attempts  have  been  made  with  forceps -or  version  by  men  of 
uncertain  asepsis  to  deliver  her,  Cesarean  section  is  contra-indicated. 
In  these  cases  the  mortality  is  from  10  to  25  per  cent.,  and  the  fetal 
vitality  is  uncertain.  The  causes  of  maternal  death  in  the  author's 
series  of  150  cases  were  as  follows: 

Extensive  carcinoma  of  cervix,  mother  in  last  stages  of  disease,  child  macer- 
ated, death  from  shock  "within  twenty-four  hours 1 

Pulmonary  embolus,  fourth  and  thirtieth  day 2 

Intestinal  obstruction,  autopsj'  showing  no  infection 1 

Toxemia  (1)  with  degeneration  of  liver,  (2)  with  urine  solid  on  boiling;  death 

within  twenty-four  hours 2 

Postpartum  hemorrhage;  death  in  three  hours 1 

Sepsis,  fourth  day,  seventeenth  day,  and  thirtieth  day 3 

10 

Fetal  Mortality. — If  the  fetus  is  alive  at  the  beginning  of  a  Cesarean 
section  and  its  vitality  has  not  been  impaired  by  attempts  at  delivery 
through  the  natural  passages,  the  fetal  mortality  is  practically  7iil. 

It  is  the  most  certain  method  of  delivering  a  living  child  which  exists. 

Repeated  Cesarean  Sections. — The  danger  of  repeated  Cesarean  sec- 
tions in  the  same  patient  differs  but  little  from  that  of  the  original, 
provided  the  operation  in  subsequent  pregnancies  is  performed  promptly. 
The  author  has  performed  Cesarean  section  four  times  on  one  of  his 


790  DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 

patients  and  five  times  on  anotlier,  and  in  each  the  convalescence  and 
snbsequent  results  were  all  that  could  ])e  desired.  On  the  other  hand, 
to  allow  a  woman  who  has  had  one  or  more  previous  Cesarean  sections 
to  remain  long  in  a  subsequent  labor  would  expose  her  to  the  risk  of  a 
thinned  uterine  cicatrix  and  perhaps  a  uterine  rupture,  as  has  been 
reported  by  several  operators. 

EXTRAPERITONEAL   CESAREAN    SECTION. 

In  order  to  avoid  the  high  mortality  of  the  classical  Cesarean  section 
when  performed  upon  a  patient  already  infected,  different  obstetric 
surgeons  in  recent  years  have  revived  old  proposals  of  incising  the 
abdominal  wall,  pushing  upward  and  backward  the  peritoneum,  open- 
ing the  uterus  and  delivering  the  child  extraperitoneally. 

As  already  stated,  the  idea  is  not  a  new  one.  Jorg,  in  1S07,  had  sug- 
gested such  a  procedure  through  a  transverse  incision,  and  this  proposal 
had  been  modified  by  Ritgen  and  the  operation  performed  by  him, 
although  unsuccessfully,  in  1820. 

Thomas,  1  of  New  York,  in  1S70,  not  only  suggested  but  successfully 
operated  through  a  lateral  incision  parallel  to  Poupart's  ligament,  an 
operation  he  called  gastro-elytrotomy  or  laparo-elytrotomy.  In  the 
hands  of  seven  different  operators  this  operation  had  a  mortality  of 
50  per  cent.  With  the  improvement  in  the  technic  and  results  of 
the  Sanger  Cesarean  section,  however,  these  extraperitoneal  methods 
fell  into  disuse  and  it  was  not  until  revived  by  Frank,  of  Cologne,  in  1907, 
and  modified  by  Latzo,  Sellheim,  Doderlein  and  others  that  extraperi- 
toneal Cesarean  section  became  popular.  Furthermore,  it  may  be 
stated  that  this  popularity  has  been  much  more  wide-spread  in  Germany 
than  in  America. 

It  is  interesting  to  note  that  the  development  of  the  operation  has 
followed  the  two  lines  suggested  by  the  early  proposers;  thus,  the  opera- 
tion through  a  transverse  incision  has  been  developed  by  Frank,  Latzo, 
and  Sellheim,  while  the  operation  through  a  lateral  incision — the  gastro- 
elytrotomy  of  Thomas — has  been  developed  by  Doderlein  and  Diihrssen. 

Technic. — The  technic  of  the  operation  has  ^'aried  as  it  iias  been 
developed  by  the  different  operators:  Thus  Frank,  by  a  transverse  inci- 
sion above  the  pubes,  opened  the  peritoneal  cavity,  separated  the  utero- 
vesical  fold  from  the  bladder  and  the  lower  part  of  the  uterus,  stitched 
this  fold  to  the  parietal  peritoneum,  opened  the  uterus  transversely 
and  delivered  or  allowed  nature  to  deliver  the  child  through  this  open- 
ing, closing  the  wounds  in  clean  cases  and  draining  through  the  cervix 
and  vagina  in  infected  cases.  This  has  been  called  the  transperitoneal 
operation.  The  technic  of  the  operation  as  modified  by  Latzo  and 
Sellheim  consists  in  making  a  Pfannenstiel  incision;  separating  the 
bladder  and  peritoneum  from  one  side  of  the  anterior  surface  of  the 
uterus;  lifting  up  the  peritoneum  and  incising  the  lower  uterine  segment 

'  Gastro-elytrotomy,  a  substitute  for  the  Cesarean  section,  Amer.  Jour.  Obst.,  1.S71,  iii, 
125-139. 


EXTRAPERITONEAL  CESAREAN  SECTION 


797 


longitudinally.  In  clean  cases  the  uterine  and  abdominal  wounds  are 
closed  after  the  removal  of  the  placenta,  while  in  infected  cases  Sell- 
heim  unites  the  edges  of  the  uterine  and  abdominal  incisions  and  drains 
with  gauze,  allowing  the  uterine  fistula  to  close  later.  In  the  lateral 
operation,  as  developed  by  Doderlein^  and  Diihrssen,  and  practised  by 
them  both  as  late  as  1911,  the  patient  was  placed  in  the  Trendelenburg 
posture  and  an  incision  made  parallel  to  Poupart's  ligament,  from  near 
the  anterior  superior  spine  to  a  point  just  above  the  symphysis.  The 
fibers  of  the  external  and  internal  oblique  muscles  were  separated  with 
as  little  cutting  as  possible;  the  epigastric  vessels  were  divided  between 
double  ligatures  and  the  rectus  muscle  was  drawn  inward  with  a  retractor. 
The  fingers  working  in  the  subperitoneal  connective  tissue  lifted  up  the 


A 

\ 

\ 

l,^^!^ 

\ 

■     "'"\^ 

X^ 

\ 
i 
•1 

A 

Fig.  482. — Extraperitoneal  Cesarean  section.      (Doderlein.) 

peritoneum  from  the  lateral  aspect  of  the  lower  uterine  segment,  which 
was  then  incised  and  the  child  delivered  usually  by  the  forceps.  In  1912 
Doderlein^  abandoned  the  inguinal  incision  as  possessing  no  advantages 
over  the  longitudinal  and  the  disadvantage  of  more  limited  space.  The 
operation  as  performed  by  Doderlein,  through  a  longitudinal  incision 
representing  one  of  the  best  technics  of  extraperitoneal  Cesarean 
section,  is  here  given  in  more  or  less  detail.  The  patient  during  the 
early  part  of  the  operation  is  placed  in  the  Trendelenburg  posture,  a 
position  Doderlein  considers  important  for  the  success  of  the  operation. 
An  incision  is  made  from  the  symphysis  to  a  hand's  breadth  below^  the 

1  Monatsschrift  f.  Geburtshlilfe  und  Gyn.,  1911,  Band  xxxiii,  Heft  1. 

2  Operative  Gynakologie,  Seiten  888-896. 


798  DELIVERY   BY   METHODS   DISTINCTLY  SURGICAL 

umbilicus,  a  little  to  the  left  of  the  median  line  (see  Fig.  482).  The 
incision  -with  gentle  strokes  of  the  knife  is  carried  down  to  the  subperi- 
toneal tissue,  care  being  necessary  to  avoid  wounding  of  the  peritoneum 
on  account  of  the  stretching  and  thinning  of  the  abdominal  wall  during 
the  pregnancy.  The  next  step  is  to  expose  the  lateral  border  of  the* 
bladder  and  the  covering  fold  of  peritoneum.  For  the  purpose  of  iden- 
tification it  is  sometimes  advisable  to  have  the  bladder  partially  filled 
during  the  early  part  of  the  operation  and  then  emptied.  The  bladder 
is  now  gently  pushed  forward  and  toward  the  median  line,  while  the 
peritoneum  is  elevated  from  the  lower  part  of  the  abdominal  wall  and 
the  lower  part  of  the  uterus  (see  Fig.  483),  care  being  taken  not  to  disturb 
the  lower  attachments  of  the  bladder  or  the  ureter,  lest  sloughing  occur, 
as  happened  in  one  of  Doderlein's  cases.    A  longitudinal  incision  is  then 


Fig.  483. — Extraperitoneal  Cesarean  section.     (Dodcrlein.) 

made  in  the  lower  uterine  segment,  avoiding  the  peritoneum  above  and 
the  ureter  below  (see  Fig.  484).  The  patient's  position  is  then  changed 
from  one  with  elevated  pelvis  to  one  with  lowered  pelvis  (see  Fig.  485), 
and  the  chikl  extracted,  usually  with  forceps,  occasionally  by  version 
and  breech  extraction.  The  placenta  is  then  expressed,  or  if  indicated 
on  account  of  hemorrhage,  is  manually  extracted.  The  patient  is  then 
placed  in  the  Trendelenburg  posture  again  and  the  wounds  in  the  uterus 
and  abdominal  wall  sutured  (see  Fig.  486),  with  or  without  drainage 
from  above  or  below,  according  to  the  probability  of  infection  before 
operation.  In  Doderlein's  clinic  58  cases  have  been  operated  on  by  this 
method.  In  53  the  indication  for  the  operation  was  a  contracted  pelvis; 
in  2,  eclampsia;  and  in  '.],  stenosis  or  rigidity  of  the  soft  parts.  In  the 
58  cases  the  maternal  mortality  was  3,  or  5.1  per  cent.;  the  fetal  mor- 
tality was  8,  or  13.8  per  cent. 


EXTRAPERITONEAL  CESAREAN  SECTION 


799 


Fig.  484. — Showing  incision  in  lower  uterine  segment.      (Doderlein  and  Kronig.) 


Fig.  485. — Extraction  of  child.    Woman  with  pelvis  lowered ;  shoulders  raised. 
(Doderlein  and  Kronig.) 


800 


DELIVERY  BY   METHODS  DISTIXCTLY  SURGICAL 


Relative  Value  of  Extraperitoneal  and  the  Sanger  Cesarean  Section. — 
In  spite  of  the  improved  tecliiiic  and  lowered  mortality  of  Sellheim 
and  Doderlein,  the  author  believes  that  the  classical  operation  of  Sanger 
is  a  better  operation  in  clean  cases  and  that  in  infected  cases  the  supe- 
riority of  the  extraperitoneal  Cesarean  section  over  the  Sanger  incision 
followed  by  a  hysterectomy  after  the  removal  of  the  child  is  still  to  be 
proved.  In  the  first  place  the  Sanger  Cesarean  section  is  a  simpler  opera- 
tion, without  the  risk  of  injury  to  the  bladder  and  ureter,  which  is  asso- 
ciated with  the  extraperitoneal  operation.  Furthermore,  the  liability  in 
the  extraperitoneal  operation  of  accidentally  opening  the  peritoneal  cavity 
in  the  blunt  dissection  in  the  subperitoneal  connecti\"e  tissue,  V)etween  the 
bladder  and  the  uterus,  with  the  possibility  of  its  infection  is  certainly 


Fig.  486. — Suturing  uterine  incision,      f  Doderlein  and  Kronig.) 

an  unfavorable  feature  of  the  operation.  Both  the  maternal  and  the 
fetal  mortality  of  the  Sanger  Cesarean  section  at  the  Sloane  Hospital 
are  lower  than  those  of  the  extraperitoneal  Cesarean  section  as  reptjrted 
from  Germany,  hence  the  author  feels  justified  in  preferring  the  former. 


POSTMORTEM   CESAREAN    SECTION. 

It  is  not  often  that  the  opportunity  arises  to  deliver  a  living  child 
after  the  death  of  the  mother,  yet  it  is  an  established  fact  that  the  child 
will  sometimes  live  from  twenty  to  thirty  minutes  after  the  heart  action 
and  respiration  of  the  mother  have  ceased.  The  length  of  time  the  child 
remains  alive  varies  with  the  cause  of  death,  of  the  mother.  Thus  the 
child  will,  as  a  rule,  live  longer  if  the  mother's  death  was  sudden  than  if 


CRANIOTOMY  AND  EMBRYOTOMY  801~ 

she  had  a  lingering  death  in  which  heart  and  respiration  had  been  faihng 
for  hours.  If  the  child  is  near  term  and  alive  at  the  time  of  the  mother's 
death,  three  alternatives  present  themselves: 

1.  Leave  the  mother  undelivered. 

2.  Deliver  by  Cesarean  section. 

3.  Deliver  through  the  natural  passages. 

The  decision  to  leave  the  woman  undelivered  must  be  governed 
largely  by  the  wishes  of  the  family.  The  author  feels  that  if  the  family 
wish  the  body  untouched,  it  is  the  duty  of  the  obstetrician  to  acquiesce. 

The  choice  between  delivery  by  Cesarean  section  and  through  the 
natural  passages  depends  upon  the  dilatation  of  parturient  canal. 

If  the  woman  was  in  labor  and  the  parts  well  dilated,  delivery  from 
below  by  forceps  or  version  offers  a  fair  chance  of  saving  the  baby  and 
seems  less  of  a  shock  to  the  family.  On  the  other  hand,  if  the  cervix 
is  not  dilated,  there  is  a  much  better  chance  of  saving  the  baby  by 
Cesarean  section,  as  any  knife  at  hand  may  be  used  for  the  operation. 
The  author  has  had  one  successful  case  of  postmortem  Cesarean  section. 

Postmortem  Delivery. — In  connection  with  postmortem  Cesarean 
section  should  be  mentioned  spontaneous  postmortem  delivery.  Occa- 
sionally a  woman  who  has  been  buried  undelivered  has  for  some  reason, 
perhaps  for  medicolegal  purposes,  been  disinterred  and  the  child  has 
been  found  in  the  casket  between  the  thighs  of  the  mother.  This  delivery 
is  usually  brought  about  by  the  formation  and  pressure  of  gases  in  the 
intestines  or  in  the  intestines  and  uterus  resulting  from  the  process  of 
putrefaction.  Some  authorities  have  laid  stress  on  the  contraction  of  the 
abdominal  and  uterine  muscles  in  rigor  mortis,  aiding  in  this  expulsion. 

CRANIOTOMY   AND   EMBRYOTOMY. 

The  reduction  in  the  size  of  the  fetal  head  by  some  cutting  or  crushing 
operation  is  called  craniotomy.  The  reduction  in  the  size  of  the  fetal 
body  by  some  similar  procedure  is  called  embryotomy.  As  the  head 
usually  presents,  or  at  any  rate  usually  offers  the  greatest  obstacle  to 
delivery,  it  is  the  operation  of  craniotomy  which  is  much  more  fre- 
quently indicated  than  an  embryotomy,  and  hence  craniotomy  will  be 
first  considered. 

Craniotomy. — ^In  this  operation  the  head  is  perforated,  crushed,  and 
extracted. 

Indications. — In  spite  of  the  advances  in  obstetric  surgery  and  the 
lessened  indications  for  craniotomy,  it  is  still  a  proper  procedure  in 
certain  cases,  and  in  the  interest  of  the  mother  may  serve  a  most  useful 
purpose.  The  usual  indication  for  craniotomy  is  delayed  labor  with  a 
dead  fetus.  If  the  mother  can  be  saved  any  additional  risk  and  suffering 
by  reducing  the  size  of  the  head  of  a  fetus  already  dead,  this  operation 
is  not  only  justifiable  but  in  most  cases  advisable.  Craniotomy  upon 
a  living  child  is  only  justifiable  in  exceptional  circumstances.  There  are 
circumstances,  however,  in  which  the  interests  of  the  mother  make  the 
procedure  justifiable.  The  following  are  examples: 
51 


S02 


DELIVERY  BY   METHODS  DISTINCTLY  SURGICAL 


In  cases  of  protracted  labor,  where  frequent,  unsuccessful  attempts 
to  deliver  the  fetus  have  been  made  and  the  fetal  vitality  as  shown  by 
the  heart  sounds  is  very  low,  craniotomy  is  indicated  both  because  the 
chances  of  the  child  sur\-iving  any  surgical  delivery  are  small,  and 
because  the  maternal  risk  of  a  surgical  delivery  like  Cesarean  section 
would  be  great. 

If  the  woman's  condition  is  desperate  when  first  seen,  as  in  an  acci- 
dental hemorrhage  with  a  complete  separation  of  the  placenta,  and  a 


1 


Fig.  487. — Taraier's  basiotribe. 


Fig.  488.— Blunt  hook. 


craniotomy  offers  the  prospect  of  less  shock  to  the  mother  than  any 
other  procedure,  craniotomy  is  indicated. 

In  hydrocephalus  craniotomy  finds  a  positive  indication. 

Finally,  if  the  obstetrician  in  charge  is  without  the  experience  or  skill 
needed  in  the  performance  of  a  Cesarean  section,  and  is  so  situated  that 
he  cannot  obtain  the  required  skill,  craniotomy  is  indicated  in  the  interest 
of  tlie  mother,  if  he  is  unable  to  deliver  the  child  by  forceps  or  version. 

Instruments  Needed. — For  a  craniotomy  upon  a  cephalic  presentation, 
a  perforator,  a  crusher  and  a  tractor  are  needed.  These  powers  are  all 
combined  in  Tarnier's  basiotribe  (see  Fig.  487),  which  is  the  instrument 


CRANIOTOMY  AND  EMBRYOTOMY 


803 


preferred  by  the  author.  The  instrument  consists  of  a  central  perforator 
and  two  blades  resembling  long  forceps  blades  which  introduce  like 
forceps  blades  on  opposite  sides  of  the  fetal  head  and  then  adjust,  the 
left  blade  to  a  pin  on  the  perforator  and  the  right  to  a  pin  on  the  left 
blade.  The  screw  as  shown  in  the  figure  furnishes  the  crushing  power, 
and  with  the  perforator  in  place  and  the  fenestrated  blades  pressed  into 
the  fetal  skull,  the  instrument  has  such  a  hold  upon  the  fetus  that  it 
may  be  used  for  powerful  traction.     If  there  is  difficulty  in  delivering 


Fig.  489. — Smellie's  scissors. 


Fig.  490. — Craniotomy  forceps. 


the  shoulders,  the  blunt  hook  shown  in  Fig.  488,  introduced  into  one 
axilla,  will  often  prove  serviceable.  For  a  craniotomy  upon  the  after- 
coming  head  a  crushing  instrument  is  usually  not  needed,  as  after 
perforation,  which  is  usually  done  behind  an  ear,  or  through  the  foramen 
magnum,  traction  on  the  fetal  body  usually  forces  out  the  brain  substance 
and  causes  the  skull  to  collapse.  In  this  case  a  smaller  perforator  is 
often  useful  and  the  Smellie's  scissors  (see  Fig.  489)  answers  nicely.  In 
rare  cases  if  a  good  application  has  not  been  secured  with  the  Tarnier 
basiotribe,  and  the  instrument  slips,  it  may  be  difficult  to  reapply,  and 
an  instrument  is  needed  with  which  a  firm  hold  can  be  obtained  upon 


804 


DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 


the  fetal  skull.  The  craniotomy  forceps  (shown  in  Fig.  490)  is  a  useful 
instrument  for  this  purpose,  one  blade  being  applied  without  and  one 
within  the  skull.  This  instrument  may  also  be  used  to  break  off,  by 
twisting,  a  portion  of  the  fetal  skull  and  so  reduce  the  bulk  of  the  head 
to  be  extracted. 

Technic. — The  patient  should  be  anesthetized  both  for  the  relief  of 
suffering  and  to  spare  her  the  mental  shock  of  seeing,  or  even  knowing, 
that  her  fetus  is  being  mutilated.  The  lithotomy  position;  the  aseptic 
preparation  and  draping  should  be  the  same  as  for  a  forceps  delivery. 
In  a  cephalic  presentation  two  fingers  of  the  left  hand  should  be  intro- 


FiG.  -191.- 


-P('rf(jrator  in  skull. 
blades  applied. 


Lateral 


Fig.  492. — Skull  cru.shcd  with  crushiiifj 
screw. 


duced,  and  a  fontanelle  or  suture  located.  Along  the  two  fingers  the 
perforator  of  the  Tarnier  basiotribe  should  be  passed  and  made  to 
enter  the  skull  through  a  suture  or  fontanelle,  as  being  easier  points  of 
entry  than  through  one  of  the  cranial  bones.  If  the  fetal  head  has  not 
engaged,  it  should  be  pushed  down  and  steadied  by  an  assistant  until 
the  perforator  has  entered.  Having  entered  the  skull  the  perforator 
should  be  passed  to  the  medulla  and  moved  about  so  as  to  make  sure 
that  the  mutilated  fetus  is  not  born  alive.  The  lateral  blades  of  the 
basiotribe  should  then  be  introduced  as  forceps  blades,  and  applied  to 
the  sides  of  the  fetal  head  (see  Fig.  491).    The  crushing  screw  should 


CRANIOTOMY  AND  EMBRYOTOMY  805 

then  be  adjusted  and  screwed  down  (see  Fig.  492).  As  the  screw  is  turned 
the  brain  substance  pours  out  of  the  vagina,  showing  the  compression 
of  the  fetal  skull.  When  the  screw  has  reached  its  limit,  the  instrument 
as  a  whole,  with  its  firm  grasp  upon  the  skull,  may  be  used  as  a  tractor 
and  the  child  delivered. 

Craniotomy  upon  the  after-coming  head  is  usually  indicated  in  a 
breech  extraction  in  which  there  has  been  so  great  difficult}'  in  the 
extraction  and  so  great  delay  in  the  delivery  that  the  fetus  has  died 
before  the  head  has  been  delivered.  The  critical  condition  of  the  mother 
may  also  indicate  craniotomy  to  secure  a  speedy  delivery.  Here,  as 
indicated  above,  only  a  perfora,tion  is,  as  a  rule,  needed,  and  this  is  accom- 
plished by  inserting  the  perforator  behind  the  ear  or  into  the  foramen 
magnum.  It  is  often  a  convenience  to  have  an  assistant  or  nurse  pull 
down  on  the  legs  of  the  fetus  while  the  obstetrician  passes  the  perforator, 
guiding  it  by  the  fingers  of  the  other  hand.  Having  churned  up  the 
fetal  brain  with  the  perforator,  the  obstetrician  then  completes  the 
delivery  of  the  head  by  the  Smellie-Veit  method.  The  compression  of 
the  perforated  head  by  the  parturient  canal,  as  the  fetus  is  extracted, 
forces  out  the  brain  substance  and  so  reduces  the  cephalic  bulk. 

Prognosis. — If  the  conjugate  diameter  of  the  mother's  pet\'is  is  7  cm., 
or  over,  the  fetal  head  engaged  and  the  mother  not  infected,  there  is 
very  little  maternal  risk  in  the  operation.  On  the  other  hand,  if  the 
conjugate  diameter  is  as  small  as  5.5  cm.  or  less,  a  Cesarean  section 
is  safer,  unless  the  mother  is  already  infected.  If  the  mother  is  already 
infected,  or  is  in  a  critical  condition  before  the  operation  is  undertaken, 
the  prognosis  is  naturally  grave. 

In  20,000  consecutive  labors  at  the  Sloane  Hospital  there  were  188 
craniotomies;  1  to  106 

Primigravidse 103 

Multigravidse 85 

Condition  of  fetus  at  time  of  operation: 

Dead .      149 

Non-\iable      ........        32 

fHydrocephalic 3 

Alive  and  viable 7  \  Failing  fetal  heart 1 

[in  fair  condition  but  mother  in  extremis       3 

188 

Critical  condition  of  the  mother       .      .      .      ." 134 

Operation  on  fore-coming  head 92 

Operation  on  after-coming  head 96 

Maternal  mortahty  (none  due  to  operation  save  perhaps  1  from  shock). 

Maternal  deaths 50 —26.5  per  cent. 

Eclampsia 18 

Toxemia  of  pregnancy 8 

Chronic  nephritis 1 

Sepsis 15 

Rupture  of  uterus 3 

Accidental  hemorrhage 2 

Endocarditis 1 

Malignant  endocarditis 1 

Shock 1 


806 


DELIVERY  BY  METHODS  DISTINCTLY  SURGICAL 


Embryotomy. — This  consists  in  reducing  the  bulk  of  the  fetal  body 
or  in  severing  it  from  the  head.  The  operation  receives  difterent  names 
according  to  the  procedure.  Thus,  separating  the  head  from  the  trunk 
is  called  decapiialiou.  Opening  the  thorax  or  the  abdomen  and  with- 
drawing the  viscera  is  called  evisceration.  Division  of  the  clavicle  to 
reduce  an  excessive  size  of  the  shoulders  is  called  a  cleidotomy. 

Instruments  Needed. — For  the  different  operations  included  imder  the 
term   enihryoUnuii,  a   strong,  blunt-pointed,  curved   scissors    (Fig.  493) 


r 


Fig.  493. — Strong,  blunt-pointed,  curved 
scissors. 


Fig.  494. — Braun's  sharp-edged, 
blunt-pointed  hook. 


will  usually  answer  the  purpose.  For  a  decapitation  the  sharp-edged, 
blunt-pointed,  Braun's  hook  (Fig.  494),  will  sometimes  be  preferable, 
but  the  obstetrician  should  be  able  to  do  all  of  these  operations  with 
the  scissors. 

Indications. — The  chief  indication  for  a  decapitation  is  an  impacted 
shoulder  presentation,  where  version  is  contra-indicated  on  account 
of  the  danger  of  rupture  of  the  uterus.  If  the  neck  cannot  be  reached 
evisceration  is  then  usually  indicated. 


CRANIOTOMY  AND  EMBRYOTOMY  807 

Technic. — With  the  patient  in  the  hthotomy  position  and  with  the 
usual  aseptic  preparation  and  draping,  the  different  varieties  of  embry- 
otomy are  performed  as  f ohows : 

Decapitation. — In  a  case  of  impacted  shoulder  presentation  with  a 
tonic  uterus  and  the  fetal  neck  within  reach,  the  indication  as  stated 
above  is  a  decapitation.  With  the  fingers  of  one  hand  inserted  along 
the  vagina  as  a  guide,  the  sharp-edged,  blunt-pointed,  Braun's  hook  is 
passed  along  them  and  hooked  over  the  fetal  neck.  Partly  by  a  pulling 
and  partly  by  a  twisting  motion,  this  hook  is  made  to  sever  the  head 
from  the  body  while  the  vaginal  fingers  guard  the  maternal  soft  parts 
from  injury  from  the  hook.  The  same  operation  of  decapitation  may  be 
performed  by  the  heavy,  blunt  scissors  shown  in  Fig.  493,  which  are 
guided  by  the  vaginal  fingers  to  the  neck  and  are  then  used  to  separate 
the  head  from  the  trunk.  After  decapitation,  the  head  is  pushed  up  out 
of  the  way,  and  the  child  extracted  by  the  arm,  or  a  podalic  version  is 
performed.  This  is  followed  by  the  delivery  of  the  severed  head.  If  the 
shoulder  presentation  is  so  impacted  that  the  fetal  neck  cannot  be 
reached,  it  is  usually  necessary  to  reduce  the  bulk  of  the  trunk  by  evis- 
ceration. Using  the  same  scissors  shown  in  Fig.  493,  and  passing  them 
along  the  vaginal  fingers  to  the  thorax,  this  is  entered  by  the  section  of 
two  or  more  ribs;  the  diaphragm  is  then  opened  through  the  thorax,  so 
that  the  obstetrician's  hand  can  be  passed  into  the  fetal  abdomen. 
Working  partly  with  the  hand  and  partly  with  the  scissors,  one  viscus 
after  another  can  be  removed  until  the  trunk  will  so  collapse  as  to  render 
podalic  version  an  easy  and  safe  procedure,  even  with  a  tonic  uterus. 
When  with  a  cephalic  presentation  of  a  dead  child  the  labor  is  obstructed 
on  account  of  excessive  size  'of  the  shoulders,  this  excessive  bulk  can  be 
reduced  by  section  of  one  or  both  clavicles  by  the  strong  scissors  men- 
tioned above.  The  section  of  the  clavicles  allows  the  shoulders  to  fold 
inward  and  thus  greatly  shortens  the  bisachromial  diameter.  In  an 
impacted  shoulder  presentation  with  a  dead  child  and  a  deformed  pelvis 
the  author  has  occasionally  found  it  necessary  with  the  scissors  not  only 
to  divide  the  clavicle,  but  also  to  separate  the  scapula  from  the  thorax 
and  remove  one  arm  with  scapula  and  part  of  the  clavicle  before  he  could 
deliver  the  child.  Enough  has  been  written  to  show  that  with  the  scissors 
the  obstetrician  can  reduce  the  fetal  bulk  as  may  be  necessary  in  the 
different  forms  of  embryotomy. 


PART  YI. 
PATHOLOGICAL  PUEEPERIUM. 


CHAPTER  XXVIII. 
PUERPERAL  INFECTION. 

Puerperal  infection  is  the  term  used  to  cover  the  various  local  and 
general  pathological  conditions  resulting  from  the  invasion  of  the  par- 
turient canal  during  labor  or  the  puerperium  by  various  pathogenic 
organisms. 

Puerperal  infection  was  for  centuries  shrouded  in  mystery.  It  was 
regarded  as  the  result  of  retention  of  the  lochia;  as  a  metastasis  of  the 
milk;  as  a  specific  fever;  as  an  interposition  of  divine  providence,  etc. 

It  was  not  until  about  the  middle  of  the  last  century  that  correct 
views  regarding  the  etiology  of  puerperal  infection  were  obtained  and 
published.  The  two  men  to  whom  we  probably  owe  most  for  this  knowl- 
edge were  Oliver  Wendell  Holmes,  of  this  country,  who  in  1843  pub- 
lished a  paper  on  "The  Contagiousness  of  Puerperal  Fever,"  and  Ignaz 
Phillipp  Semmelweiss,  an  assistant  in  the  ]\Iaternity  Department  of 
the  General  Hospital  of  Vienna,  who  in  1847  was  impressed  with  the 
frightful  mortality  among  the  women  in  certain  wards  attended  by  the 
medical  students  as  compared  with  the  mortality  in  other  wards  attended 
by  midwives  and  among  patients  delivered  outside  the  hospital.  He 
set  about  finding  the  cause  of  the  terrible  death-rate  and  conceiving  the 
idea  that  it  was  due  to  the  fact  that  students,  coming  directly  from  the 
autopsy  room  to  maternity  work,  carried  infective  material  from  the 
autopsy  table  to  the  parturient  women  whom  they  examined,  made 
them  wash  their  hands  in  chlorin  water  before  this  examination.  Under 
this  regime  the  mortality  fell  at  once  from  over  10  per  cent,  to  1  per 
cent.,  and  Semmelweiss  became  convinced  that  puerperal  infection 
was  wound  infection,  and  from  that  time  until  he  lost  his  reason  as  a 
result  of  ridicule  and  opposition,  he  spent  a  large  part  of  his  time  and 
strength  in  -endeavoring  to  impress  these  views  upon  the  medical  world.. 
It  was  not,  however,  until  after  the  introduction  of  antiseptic  methods 
in  surgery  by  Lister  and  the  bacteriological  study  of  Pasteur  that  the 
profession  at  large  began  to  accept  the  fact  that  puerperal  infection  was 
like  general  wound  infection,  and  could  be  largely  prevented. 

Etiology.- — In  order  to  understand  the  etiology  of  puerperal  infection 
and  the  safeguards  with  which  nature  surrounds  the  parturient  canal 
one  must  consider  the  normal  bacteriology  of  the  vagina  and  then  the 

(809) 


810  PUERPERAL  INFECTION 

microorganisms  which  usually  cause  infection.  As  a  result  of  the  careful 
bacteriological  work  of  Kronig  and  Mengc  in  1897,  and  of  Williams  in 
1898,  and  Bergland  in  19l)(),  each  obtaining  the  vaginal  secretion  for 
examination  by  means  of  a  small  glass  tube  which  could  be  introduced 
into  the  vagina  without  touching  the  labia  or  the  hymen,  it  has  been 
demonstrated  that  the  vagina  of  the  normal,  pregnant  woman  does  not 
contain  the  ordinary  pyogenic  cocci  and,  furthermore,  that  the  vagina 
has  certain  bactericidal  properties,  so  that  cultures  of  streptococci  and 
staphylococci  introduced  within  it  disappear  in  from  twelve  to  twenty 
hours.  The  l)actericidal  power  of  the  vagina  is  probably  due  in  part 
to  its  acid  reaction,  which  is  probably  produced  by  a  number  of  different 
bacteria  with  which  it  abounds  from  birth,  among  them  being  the  vaginal 
bacillus  of  Doderlein.  It  is  probably  also  due  in  part  to  phagocytosis 
and  the  germicidal  power  of  the  normal  mucus  and  epithelium. 

The  acid  reaction  of  the  vagina  explains  also  why  the  gonococcus 
withstands  the  bactericidal  power  of  this  canal  to  which  the  strepto- 
coccus and  the  staphylococcus  succumb,  because  the  gonococcus  lives 
and  thrives  in  an  acid  medium. 

The  practical  obstetrician  may  then  consider  the  vagina  of  the  normal 
pregnant  woman  as  sterile,  and  that  even  if  pathogenic  organisms  have 
been  introduced  they,  with  the  exception  of  the  gonococcus,  have  disap- 
peared if  the  woman  has  no  fever  and  the  vagina  has  been  left  untouched 
for  a  few  days. 

On  the  other  hand,  the  vvdva  abounds  in  pyogenic  organisms:  the 
colon  bacillus  from  the  neighboring  rectum;  the  staphylococcus  found 
anj'^vhere  on  the  skin,  and  frequently  the  streptococcus  and  other  pyo- 
genic organisms. 

We  have  then,  as  a  rule,  a  sterile  vagina  within  and  a  non-sterile 
vulva  without. 

The  various  pathogenic  organisms  at  the  threshold  of  the  vagina  will 
first  be  considered  a  little  more  in  detail  and  then  the  means  of  transfer 
from  without  inward. 

The  Streptococcus. — The  most  virulent  types  of  puerperal  infection 
are  usually  the  result  of  the  invasion  of  the  parturient  canal  by  the 
Streptococcus  pyogenes.  For  a  time  the  infection  may  remain  localized, 
but  there  is  always  a  tendency  for  it  to  spread  by  the  bloodvessels  and 
lymphatics  until  the  pelvic  organs,  the  peritoneum  and  perhaps  the 
general  system  are  involved. 

The  Staphylococcus. — Although  invasion  by  the  staphylococcus  is 
usually  considered  to  result  in  a  less  virulent  type  of  infection  than  by 
the  streptococcus,  it  is  often  a  serious  infection  by  itself  and  not  infre- 
quently is  found  combined  with  the  streptococcus.  The  Staphylococcus 
aureus  is  the  variety  usually  found. 

The  Gonococcus. — This  organism  which  thrives  in  an  acid  medium, 
is  often  found  in  the  cervical  canal,  Skene's  ducts  and  Bartholin's  ducts, 
and  has  recently,  through  the  work  of  Taussig  and  Stone  and  MacDonald, 
come  to  be  regarded  as  the  cause  of  a  considerable  number  of  rises  of 
temperature  in  the  puerperium.    As  a  rule  the  gonococcus  infection  has 


ETIOLOGY  OF  PUERPERAL  INFECTION  811 

a  tendency  to  localize  itself  and  the  result  not  be  fatal,  but  occasionally, 
especially  in  a  mixed  infection,  it  gives  rise  to  a  fatal  septicemia. 

The  Bacillus  Coli  Communis. — When  one  considers  the  proximity  of 
the  rectum  to  the  vaginal  orifice,  especially  if  the  perineum  has  been 
lacerated  and  the  vulva  is  gaping,  it  is  easy  to  understand  the  possibility 
of  infection  by  the  colon  bacillus.  The  author  once  lost  a  case  of  symphy- 
seotomy in  which  a  bacteriological  examination  showed  almost  a  pure 
culture  of  colon  bacilli.  This  was  a  case  which  on  account  of  her  weight 
and  the  strapping  of  the  hips,  combined  with  loose  bowels,  it  was  very 
difficult  for  the  nurse  to  keep  clean. 

The  Bacillus  aerogenes  capsulatus  or  the  gas  bacillus  of  Welch,  has 
occasionally  been  the  organism  found  in  puerperal  infection,  as  reported 
by  Welch,  in  1900,  who  at  that  time  reviewed  the  literature  of  the  sub- 
ject. Other  series  have  been  reported.  In  the  series  reported  by  Little, 
in  1905,  from  the  Obstetrical  Department  of  the  Johns  Hopkins  Hos- 
pital, only  one  presented  a  pure  culture  of  the  gas  bacillus,  the  others 
being  associated  with  other  bacteria,  especially  the  streptococcus. 

As  the  gas  bacillus  usually  exists  as  a  saphrophyte  upon  dead  tissue 
and,  as  a  rule,  does  not  invade  the  deep  tissues,  the  prognosis  is  good  when 
it  is  the  only  organism  present,  but  when  the  infection  is  mixed,  the  gas 
bacillus  being  associated  with  the  streptococcus,  the  prognosis  is  grave. 

The  Klebs-Loeffler  Bacillus. — For  many  years  the  grayish  slough  often 
seen  in  the  lower  portion  of  the  parturient  canal,  as  on  lacerations  of  the 
perineum  and  cervix  in  puerperal  infection,  was  spoken  of  as  diphtheritic, 
and  regarded  as  an  expression  of  infection  with  diphtheria.  When 
bacteriology  definitely  settled  the  organism  of  diphtheria  and  the  grayish 
sloughs  of  puerperal  infection  were  found,  as  a  rule,  not  to  contain  it, 
the  pendulum  swung  so  far  as  to  cause  the  claim  to  be  made  that  true 
diphtheria  of  the  vagina  did  not  occur. 

This  claim  is  too  radical,  as  proved  by  a  case  of  the  author's,  in  which 
the  Klebs-Loeffler  bacillus  was  isolated  from  the  vagina  of  a  patient  and 
at  the  same  time  other  members  of  the  family  had  the  usual  evidences 
of  diphtheria  in  the  throat.  Of  course  a  true  diphtheritic  membrane  in 
the  vagina  indicates  treatment  with  antitoxin  just  as  plainly  as  though 
it  was  located  on  the  tonsils  or  fauces. 

Bacillus  Typhosus. — Certain  long  cases  of  puerperal  infection  sometimes 
present  a  resemblance  both  in  the  general  appearance  of  the  patient  and 
in  the  temperature  chart  to  typhoid  fever,  but  the  only  safe  rule  to 
follow  is  to  consider  a  fever  after  confinement  as  due  to  puerperal  infec- 
tion rather  than  typhoid  fever,  unless  the  Widal  reaction  or  a  positive 
typhoid  culture  is  obtained.  Occasionally  a  surprise  in  this  direction 
will  occur,  but  it  is  extremely  rare. 

Other  pathogenic  organisms  are  occasionally  found  associated  with 
puerperal  fever,  but  not  with  sufficient  frequency  to  merit  mention  here. 

The  Carriers  of  Infection. — With  the  vulva  swarming  with  bacteria 
the  question  of  etiology  in  puerperal  infection  concerns  itself  chiefly 
with  the  means  of  transfer,  or  the  carriers  of  these  pathogenic  organisms 
from  the  vulva  without  to  the  vagina  and  upper  parturient  canal  within 


812  PUERPERAL  INFECTION 

and  above.  Although  the  reaction  of  the  vagina  during  pregnancy  is 
acid  and  the  canal  possesses  certain  bactericidal  power,  as  already  stated, 
after  delivery  this  is  changed,  the  reaction  becomes  alkaline,  numerous 
abrasions  in  the  vagina  and  cervix  usually  exist,  even  if  small,  and  the 
uterine  cavity  presents  a  large,  raw  surface,  all  presenting  an  excellent 
culture  field  for  bacteria  if  once  they  pass  the  vaginal  orifice.  The  means 
of  transfer  is  unfortunately  easy.  Anything,  no  matter  how  clean  in 
itself,  rubbing  past  the  labia  and  entering  the  vagina,  easily  carries  the 
infecting  organisms  from  the  former  and  inoculates  the  latter.  The 
importance  of  this  may  well  be  emphasized.  No  matter  how  clean 
the  fingers  or  how  sterile  the  gloves,  if  they  are  introduced  into  the 
vagina  without  separating  the  labia,  they  may  wipe  off  infective  material 
from  the  vulva  and  infect  the  vagina.  It  follows  from  this  that  the 
only  safe  method  of  making  a  vaginal  examination  is  by  a  careful  sepa- 
ration of  the  labia,  during  the  introduction  of  the  examining  fingers. 

If  infection  of  the  vagina  and  parturient  canal  can  thus  be  carried  by 
the  introduction  of  a  clean  object,  how  much  greater  the  danger  from 
one  which  is  not  clean. 

It  is  now  well  established  that  the  usual  causes  of  puerperal  infection 
are  the  unclean  fingers  and  instruments  of  the  surgically  unclean  obstet- 
rician, and  the  service  which  Semmelweiss  rendered  to  parturient  women 
and  to  the  world  was  in  teaching  the  medical  profession  the  danger  of 
unclean  hands  in  obstetrics.  Of  course  other  objects,  like  dirty  douche 
tips,  may  carry  infection  to  the  vagina.  Sexual  intercourse  just  before 
the  admission  of  the  patient  in  labor  has  more  than  once  in  the  author's 
hospital  service  been  traced  as  the  source  of  infection.  For  many  years 
bad  air,  such  as  air  impregnated  with  sewer  gas  and  bad  general  sur- 
roundings, were  held  responsible  for  puerperal  infection.  It  is  now 
known  that  these  have  little  effect  save  perhaps  in  lowering  the  vitality 
and  general  resistance  of  the  patient,  and  the  good  results  obtained  in 
the  out-patient  services  of  maternity  hospitals  show  that  in  the  most 
squalid  and  wretched  homes,  a  woman  can  have  a  safe  delivery  and 
normal  convalescence  provided  the  obstetrician's  hands,  instruments  and 
technic  are  strictly  clean. 

Is  Auto-infection  Possible? — So  thoroughly  are  the  profession  and  the 
laity  at  the  present  day  educated  to  the  fact  that  most  cases  of  puerperal 
infection  are  due  to  some  fault  in  the  technic  of  the  obstetrician, 
either  in  the  cleanliness  of  his  hands  or  instruments,  or  in  his  conduct 
of  the  delivery,  that  it  well  behooves  one  to  ask  the  question.  Can 
puerperal  infection  occur  without  its  being  the  obstetrician's  fault? 
Before  answering  this  question  let  us  consider  some  of  the  conditions 
which  favor  infection.  In  the  first  place  anything  lowering  the  vitality 
of  the  woman  as  a  whole,  and  of  the  parturient  canal  in  particular,  favors 
the  development  of  puerperal  infection.  Thus  a  poor  general  condition; 
a  long,  dry  labor  with  prolonged  pressure;  the  occurrence  of  a  hemor- 
rhage; the  occurrence  of  lacerations;  these  all  present  a  lowered  vitality 
with  a  lessened  resistance  to  the  entry  and  development  of  pathogenic 
bacteria.    So  common,  at  any  rate,  is  a  slight  rise  of  temperature  seen 


ETIOLOGY  OF  PUERPERAL  INFECTION  813 

ill  cases  who  have  had  marked  hemorrhage,  that  it  comes  to  be  rather 
expected. 

Most  obstetricians  are  agreed  today  that  cases  of  puerperal  infection 
occasionally  occur  in  which  the  obstetrician  is  not  in  the  slightest  degree 
responsible  for  the  condition : 

A  toxic  woman  may  have  an  accidental  hemorrhage.  The  uterus  of  a 
woman  whose  vitality  is  reduced  by  hemorrhage  does  not  contract  well, 
and  in  spite  of  precautions  small  clots  may  be  retained.  This  may  give 
rise  to  a  sapremia,  and  if  the  woman  is  carrying  pathogenic  germs  in  any 
part  of  her  parturient  canal,  as  in  cervix,  Skene's  ducts,  or  Bartholin's 
ducts,  the  sapremia  may  be  followed  by  a  septicemia,  without  the  obstet- 
rician being  in  any  way  responsible  for  it.  Again,  a  woman  may  have 
a  normal  temperature  and  pulse  for  a  week,  or  later  yet  a  stenosis  at 
the  internal  os,  perhaps  produced  by  a  flexion,  either  anterior  or  pos- 
terior, may  cause  a  retention  of  lochia  with  a  sapremia,  which  may  be 
the  starting-point  of  a  septicemia,  as  in  the  preceding  case.  In  these 
senses  auto-infection  is  occasionally  possible. 

With  infection  of  the  parturient  canal  apparently  so  easy,  the  wonder 
is  not  that  the  calamity  occasionally  occurs,  but  that  at  the  present 
day  it  occurs  so  seldom.  The  natural  provisions  against  infection  are 
important  and  deserve  recognition.  In  the  first  place  there  is  the  general 
resistance  of  the  normal,  healthy  tissue  to  the  invasion  of  bacteria  and 
the  provision  for  their  destruction  by  phagocytosis  if  invasion  is 
attempted.  Moreover,  the  discharge  of  fluids,  liquor  amnii  and  blood, 
is  downward  and  tends  to  cleanse  the  parturient  canal  by  flushing. 
Again,  the  birth  of  the  child  tends  to  wipe  out  the  canal  as  it  descends. 
Furthermore,  the  chorion  and  placenta  remain,  as  a  rule,  attached  to 
the  uterine  wall  until  the  child  is  born,  thus  serving  as  a  protection  to 
the  uterine  sinuses  and  when  the  placenta  and  membranes  finally  sepa- 
rate and  are  expelled,  they,  too,  wipe  the  walls  of  the  lower  portion  of 
the  canal,  and  finally  the  discharge  of  lochia  is  downward  and  outward, 
tending  still  further  to  cleanse  it. 

Relation  between  Contagious  Diseases  and  Puerperal  Infection. — Puer- 
peral infection  has  not  infrequently  occurred  in  the  practice  of  the 
general  physician  who  attended  cases  of  scarlet  fever,  measles,  etc.,  and 
at  the  same  time  was  doing  obstetric  work.  The  question  naturally 
arises,  What  is  the  connection  between  these  contagious  diseases  and 
puerperal  infection?  At  the  present  day  it  is  established  that  scarlet 
fever  and  measles  do  not  in  themselves  produce  puerperal  infection. 
In  fact  the  scarlet  fever  and  the  measles  themselves  may  be  carried  to 
the  pregnant  or  puerperal  patient  and  yet  she  does  not  develop  puerperal 
infection. 

In  the  winter  of  1910-1911,  a  season  when  there  was  a  large  amount  of 
scarlet  fever  in  New  York,  1 1  patients  in  the  Sloane  Hospital  developed 
scarlet  fever,  9  were  postpartum  cases  and  2  antepartum  cases.  They 
all  passed  through  the  regular  course  of  the  disease,  and  recovered  with- 
out either  having  puerperal  infection  themselves  or  giving  it  to  the 
others  in  the  hopsital. 


814  PUERPERAL  INFECTION 

The  danger  lies  in  the  fact  that  scarlet  fever  and  measles,  especially 
the  former,  are  frequently  complicated  by  streptococcus  infections  and 
these  streptococci  which  are  the  cause  of  the  most  virulent  types  of 
puerperal  infection  may  be  carried  by  the  hand  of  the  obstetrician  to 
his  parturient  patients. 

The  danger  of  attending  erysipelas  and  obstetric  cases  at  the  same 
time  has  been  known  for  years,  and  the  explanation  is  easy  when  it  is 
considered  that  the  streptococcus  peculiar  to  erysipelas,  the  strepto- 
coccus of  Fehleisen,  is  practically  identical  with  the  streptococcus  found 
in  the  grave  cases  of  puerperal  infection.  In  these  cases  the  medium  of 
transfer  is  usually  the  hands  of  the  physician  and  in  the  same  way  these 
same  hands  may  be  the  cause  of  infection  if  from  dressing  ulcers  of  the 
legs,  examining  throats,  etc.,  i.  e.,  the  everj-day  work  of  the  general 
practitioner,  they  pass  to  examining  women  in  labor.  The  use  of  sterile 
rubber  gloves,  enabling  him  to  have  sterile  hands  after  his  general  work, 
has  proved  a  great  boon  to  physicians  with  conscience,  and  to  their 
pregnant  patients,  but  unless  it  is  absolutely  necessary,  no  physician, 
even  with  the  protection  of  sterile  gown,  and  rubber  gloves,  should 
attend  such  cases  as  erysipelas,  diphtheria,  etc.,  and  do  obstetric  work 
at  the  same  time. 

Some  men  seem  to  carry  infection  with  them  in  spite  of  precautions. 
This  is  seen  in  the  record  of  certain  internes  in  a  hospital  service  where 
the  services  change  every  few  months.  The  experience  of  Dr.  Rutter 
of  Philadelphia,  which  has  been  quoted  in  most  text-books  for  years, 
is  so  instructive  that  it  is  worthy  of  repetition.  Dr.  Rutter's  obstetric 
work  was  followed  by  an  almost  continuous  series  of  puerperal  infection, 
while  his  fellow  practitioners  had  little  if  any.  Discouraged  by  the 
results  of  his  work  he  decided  to  take  a  long  vacation.  On  his  return, 
however,  the  same  scourge  of  puerperal  infection  pursued  him  and  at 
his  death  the  cause  of  it  all  was  clear  when  it  was  found  that  he  had 
suffered  during  life  with  an  ozena  which  had  constantly  contaminated 
his  handkerchiefs  and  his  hands.  This  was  before  the  routine  use  of 
sterile  rubber  gloves  in  obstetrics. 

Varieties.^ — Puerperal  infection  may  well  be  classified  as  either  a 
toxemia  or  a  bacteremia  and  described  as  follows: 

1.  A  Toxemia. — Due  to  the  absorption  of:  (a)  The  products  of  putre- 
factive bacteria,  often  called  a  sapremia  (Figs.  495,  496,  and  497).  (b) 
The  toxins  of  distinctive  pathogenic  bacteria. 

2.  A  Bacteremia. — In  which  bacteria  circulate  in  the  blood,  called  also 
septicemia  (Fig.  498). 

The  distinction  between  these  two  classes  is  clear.  In  the  latter, 
the  bacteria  are  in  the  general  system.  In  the  former  they  are  localized 
and  do  not  circulate. 

It  must  be  borne  in  mind,  how^ever,  that  in  actual  practice  the  two 
classes  are  not  infrequently  mingled,  the  sapremia  ser\ing  as  a  port  of 
entry  for  a  bacteremia,  so  that  when  a  case  is  first  seen  it  may  be  impos- 
sible to  tell  whether  the  infection  is  to  result  in  a  bacteremia  or  not. 

There  is  one  type  of  bacteremia  which  presents  a  distinct  clinical 
picture  and  has  long  been  called  by  a  distinctive  term  pyemia. 


FREQUENCY  OF  PUERPERAL  INFECTION 


815 


This  is  especially  apt  to  occur  in  cases  in  which  one  of  the  lesions  is 
a  thrombophlebitis,  and  in  which  ,  portions  of  the  septic  thrombus  or 
colonies  of  bacteria  becoming  detached,  are  carried  to  previously  unin- 
fected tissue.  This  is  sometimes  called  mestastatic  bacteremia  and  pre- 
sents the  clinical  picture  of  recurrent,  wide  excursions  of  temperature 
with  repeated  rigors,  as  one  new  organ  or  tissue  after  another  is  involved. 


Fig.  495. — Sapremia  from  retained  secundines. 


Fig.  496. — Sapremia  from  retained  lochia 
due  to  an  anteflexion. 


Fig.  497. — Sapremia  from  retained  lochia 
due  to  a  retroflexion. 


Frequency. — Statistics  regarding  puerperal  infection  at  the  present 
day  are  so  difficult  to  obtain  that  the  records  of  puerperal  infection  in 
20,000  consecutive  deliveries  at  the  Sloane  Hospital,  where  any  rise  of 
temperature  in  the  puerperium  above  100.6°  F.  is  considered  fever,  are 
given.    It  should  be  remembered  that  many  of  the  cases  were  brought 


816 


PUERPERAL   INFECTION 


to  the  hospital  after  l)eiiig  long  in  labor,  after  unsuccessful  efforts  at 
delivery  had  been  made,  and  that  many  were  already  infected. 

In  the  20,000  deliveries  there  was  fever,  i.  e.,  temperature  above  100.6°  F. 
in  2155,  or  10.7  per  cent. 

Of  this  number,  1288  were  primigravidse,  867  were  multigravidae,  and 
372  were  premature  deliveries  (under  eight  and  a  half  months). 

Variety  of  Infection. — Of  the  2155  cases  of  infection,  253  were  bacter- 
emia and  1902  were  sapremia. 

Thus,  in  20,000  consecutive  deliveries,  .including  ambulance  cases, 
there  were  253  cases  of  bacteremia,  or  1.25  per  cent.;  and  1902  cases  of 
sapremia,  or  9.5  per  cent. 


Fig.  498. — Bacteremia  with  site  of  invasion  in  vagina,  at  cervix  or  placental  site. 

The  use  of  rubber  gloves  was  introduced  at  the  beginning  of  the 
seventeenth  thousand,  so  that  in  this  series  of  20,000  deliveries,  16,000 
were  delivered  without  gloves  and  4000  with  gloves. 

In  the  16,000  cases  delivered  without  gloves,  there  were:  181  cases 
of  bacteremia,  or  1.1  per  cent.,  and  1525  cases  of  sapremia,  or  9.5 
per  cent. 

In  the  4000  cases  delivered  with  gloves  there  were  34  cases  of  bacter- 
emia, or  0.35  per  cent.,  and  377  cases  of  sapremia,  or  9.4  per  cent. 

The  number  of  cases  of  bacteremia  was  greatly  reduced  by  the  use 
of  rubber  gloves,  while  the  number  of  cases  of  sapremia  remained  practi- 
cally unchanged. 

Maternal  Mortality. — In  the  2155  cases  of  infection  occurring  in  20,000 
deliveries  there  were  54  maternal  deaths,  a  mortality  from  infection  of 


LESIONS  AND  PHYSICAL  SIGNS  OF  PUERPERAL  INFECTION      817 

0.27  per  cent.,  and  a  percentage  of  mortality  among  the  2155  cases  of 
2.5  per  cent. 

Among  the  253  cases  of  bactejemia  there  were  54  deaths,  or  21.3 
per  cent. 

Among  the  1902  cases  of  sapremia  there  were  no  deaths  from  infection, 
but  2  died  from  necrosis  of  the  hver,  a  mortaUty  of  0.1  per  cent. 

The  Site  of  Infection. — Any  portion  of  the  parturient  canal  may  serve 
as  the  site  of  invasion  by  pathogenic  bacteria  (see  Fig.  498).  The  entry 
may  be  in  some  small  laceration  in  the  vulva  or  vagina.  It  may  be 
higher  up  in  a  laceration  of  the  cervix,  but  the  usual  site  of  the  lesion  in 
puerperal  infection  and  the  usual  avenue  of  entrance  is  the  endometrium, 
and  especially  at  the  placental  site.  Here  is  a  large,  bleeding  surface 
with  a  considerable  amount  of  torn  tissue  and  large  sinuses  filled 
immediately  after  labor  with  soft  thrombi.  These  are  conditions 
furnishing  a  good  soil  for  the  growth  and  development  of  pathogenic 
bacteria. 

Pathological  Lesions  and  Physical  Signs. — The  pathological  changes 
in  puerperal  infection  vary  greatly  as  to  whether  the  case  is  one  of  a 
toxemia  (sapremia)  resulting  from  the  invasion  by  putrefactive  bacteria 
of  organic  material  left  in  the  uterus,  or  whether  it  is  a  bacteremia  with 
pathogenic  organisms  circulating  in  the  blood. 

In  a  sapremia,  inspection  of  the  vulva,  vagina  and  cervix  shows  a 
normal  condition  of  this  portion  of  the  parturient  canal,  with  any  abra- 
sions, which  may  have  been  produced  by  the  labor,  healthy  and  without 
exudate;  the  lochia  usually  not  diminished,  sometimes  profuse  and 
often  with  an  odor  which  is  distinctly  offensive.  This  offensive  odor  is 
usually  most  marked  when  the  bacteria  present  are  those  of  putrefaction 
or  the  colon  bacilli. 

On  the  other  hand,  the  parturient  canal  in  the  early  days  of  a  sexeve 
bacteremia  presents  a  decidedly  different  picture;  an  inspection  of  the 
vulva,  vagina  and  cervix  often  discloses  the  fact  that  any  abrasion  along 
the  canal  produced  by  the  labor  is  covered  with  a  grayish  superficial 
slough,  somewhat  resembling  the  membrane  of  diphtheria  and  formerly, 
before  the  etiological  relation  between  the  Klebs-LoefHer  bacillus  and 
true  diphtheria  was  understood,  called  "diphtheritic."  The  lochia  in 
a  case  of  bacteremia  is  usually  diminished,  may  even  be  absent,  and 
unless  there  is  associated  with  it  a  sapremia,  it  is  often  free  from  odor. 
The  uterus  is  subinvoluted  and  the  grayish  superficial  necrosis  seen  upon 
the  cervix  may  extend  over  the  whole  interior  of  the  uterus,  so  that 
the  endometriiun  becomes  a  grayish  or  greenish-gray,  necrotic  membrane. 
Beneath  the  necrotic  membrane  invaded  with  bacteria  and  in  inverse 
proportion  to  the  virulence  of  the  bacteria  and  the  rapidity  of  the 
invasion,  is  found  in  the  uterine  musculature  a  zone  of  leukocyte  infiltra- 
tion, sometimes  spoken  of  as  the  "protective  zone,"  which  as  this  term 
implies,  seems  to  serve  as  a  barrier  against  the  further  invasion  of  the 
system  of  the  woman  by  the  advancing  host  of  bacteria. 

This  protective  zone  is  thickest  when  the  resistance  of  the  woman's 
tissues  is  greatest  and  the  invasion  least  virulent  and  slow.  It  is  least  in 
52 


818  PUERPERAL  INFECTION 

evidence  when  the  invading  bacteria  are  of  the  highest  virulence,  as  the 
streptococci,  and  the  invasion  most  rapid. 

The  most  common  lesion  of  puerperal  infection  is  therefore  an  endo- 
metritis associated  with  a  subinvokition  of  the  uterus  and  more  or  less 
infiltration  of  leukocytes  just  beneath  the  endometrium,  especially  at 
the  placental  site.  Thus  we  see  nature  endeavors  to  localize  puerperal 
infection  within  the  parturient  canal  and  in  this  she  is  often  successful, 
especially  if  the  invading  bacteria  are  of  low  virulence. 

Unfortunately,  on  account  of  the  virulence  of  the  invading  organisms, 
their  great  number,  the  rapidity  of  their  invasion  and  the  low  resistance 
of  the  tissue  of  the  parturient  canal,  especially  the  uterine  wall,  the 
protective  or  reaction  zone  of  leukocytes  is  in  not  a  few  cases  incapable 
of  limiting  the  infection  to  the  endometrium,  and  the  bacteria  spread  to 
the  uterine  wall,  the  cellular  tissue  outside  of  it,  the  tubes,  ovaries, 
peritoneum  and  perhaps  to  almost  any  organ  and  tissue  in  the  body. 
There  are  two  a\enues  along  which  the  invading  organisms  traNcl  from 
the  parturient  canal  to  the  neighboring  or  distant  tissues:  (o)  The 
lymphatics  and  {b)  the  veins. 

Although  both  of  these  channels  may  be  occupied  by  bacteria  in  cer- 
tain cases  of  puerperal  infection,  the  two  types  of  infection  are  fairly 
distinct,  and  as  in  the  severest  forms  the  lymphatics,  are  the  avenues 
followed,  this  variety  will  be  studied  first. 

From  the  infected  necrotic  surface  of  the  placental  site,  or  from  a 
lesion  in  the  cervix,  the  invading  organisms  may  extend  along  the  lym- 
phatics into  the  uterine  wall  and  give  rise  to  various  degrees  of  metritis, 
in  some  instances  resulting  only  in  small  aggregations  of  leukocytes 
which  may  eventually  be  absorbed;  in  other  instances  resulting  in 
multiple  abscesses  with  which  the  uterine  body  may  be  riddled.  Extend- 
ing along  these  uterine  lymphatics,  which  are  very  abundant  just 
beneath  the  peritoneum,  the  bacteria  may  traA-el  to  the  peritoneum  itself 
and  give  rise  to  a  peritoniti.^t,  which  is  usually  the  chief  lesion  found  in 
rapidly  fatal  cases  of  puerperal  infection  due  to  streptococcus  invasion, 
the  peritoneal  cavity  on  being  opened  showing  a  thin  seropurulent  fluid, 
with  little  fibrin  and  little  localization  of  the  infection. 

Cellulitis  or  Parametritis. — Instead  of  passing  along  the  lymphatics 
from  the  uterine  canal  directly  to  the  peritoneum  covering  the  upper 
portion  of  the  uterine  body,  the  organisms  may  travel  from  some  lesion 
of  the  vulva,  vagina,  cervix  or  lower  uterine  segment,  through  the 
lymphatics  to  the  subperitoneal  cellular  tissue  surrounding  the  uterus, 
i.  e.,  in  the  broad  ligaments  at  the  side,  the  uterovesical  ligaments  in 
front,  and  the  uterosacral  ligaments  behind  the  uterus,  setting  up  a 
cellulitis  which  resembles  that  of  the  hand  and  forearm  following  an 
infected  wound  of  the  finger  acquired  in  operating  or  dissecting. 

There  is  the  same  inflammatory  edema  which  may  occupy  more  or 
less  space  at  the  side  of  the  uterus,  giving  the  feel  of  a  hard  mass  fixing 
the  organ,  perhaps  pushing  it  to  the  opposite  side.  In  extreme  cases 
it  may  involve  the  cellular  tissue  on  both  sides  of  the  uterus,  extending 
between  it  and  the  bladder  in  front  and  surrounding  the  rectum  behind. 


LESIONS  AND  PHYSICAL  SIGNS  OF  PUERPERAL  INFECTION      819 

In  rare  cases  this  involvement  of  the  cellular  tissue  through  lymphatic 
infection  may  extend  down  along  the  vessels  of  the  thigh  and  secondarily 
cause  a  phlebitis  or  so-called  phlegmasia  alba  dolens,  differing  from  the 
ordinary  form  which  is  due  to  a  phlebitis,  starting  with  an  infected 
thrombus  within  the  vein. 

The  result  of  cellulitis  at  the  side  of  the  uterus  varies  with  the  extent 
and  virulence  of  the  infection.  In  some  cases  the  exudate,  although 
abundant  enough  to  fix  the  uterus  in  the  pelvis  and  present  almost  a 
board-like  feel  to  the  vaginal  fornix,  will  absorb  and  leave  only  slight 
cicatricial  tissue  behind.  In  other  cases  the  exudate  will  break  down 
into  an  abscess,  which  will  point  in  the  groin  above  Poupart's  ligament, 
or  burrow  down  in  the  posterior  or  lateral  fornix  of  the  vagina  or  down 
along  the  urethra  to  the  vulva.  In  some  instances,  if  neglected,  it  will 
rupture  into  the  rectum  behind  or  the  bladder  in  front,  not  to  mention 
the  vagina  or  other  directions  toward  which  it  was  pointing. 

Salpingitis. — Inflammation  of  the  tubes  in  puerperal  infection  may 
occur  in  one  of  three  ways : 

1.  In  a  few  cases  it  occurs  as  a  result  of  extension  of  the  infection  from 
the  endometrium  along  the  mucosa  of  the  tube. 

2.  More  frequently  salpingitis  results  from  extension  of  the  infection 
through  the  lymphatics  of  the  broad  ligament  to  the  wall  of  the  tube. 

3.  Not  infrequently  salpingitis  occurs  from  infection  of  the  mucosa  of 
the  outer  portion  of  the  tube  from  a  peritonitis  which  has  resulted  from 
lymphatic  infection  from  the  uterus. 

Abdominal  section  in  these  cases  often  shows  the  fimbriated  extremity 
of  these  tubes  patent  and  one  can  express  seropurulent  fluid  from  them. 

Oophoritis. — The  invading  organisms  may  extend  along  the  lymphatics 
of  the  broad  ligaments  to  the  hilum  of  the  ovary  setting  up  an  oophoritis 
with  or  without  suppuration,  or  in  the  same  way  that  a  salpingitis  may 
arise  secondarily  to  a  peritonitis,  so  a  Graafian  follicle  may  be  infected 
with  the  exudate  of  an  infected  peritoneum. 

Thrombophlebitis. — At  the  placental  site  hemorrhage  is  checked,  after 
the  expulsion  of  the  placenta,  by  contraction  of  the  uterine  musculature 
about  the  uterine  sinuses  and  by  the  formation  of  thrombi  within  them. 
.  Localized  uninfected  thrombosis  is  therefore  a  physiological  process  in 
every  parturition.  It  is  easily  understood,  however,  that  these  thrombi 
furnish  an  excellent  medium  for  the  development  and  spread  of  infection, 
when  once  infective  organisms  are  brought  to  them.  The  area  in  which 
the  thrombi  are  infected  may  be  a  limited  one,  the  process  not  extending 
beyond  the  uterine  wall,  and  recovery  rapidly  take  place.  On  the  other 
hand,  the  infected  thrombi  may  be  associated  with  an  inflammation  of 
the  vein — a  thrombophlebitis  which  extends  to  almost  all  the  veins  of 
the  pelvis,  perhaps  reaching  upward  to  their  junction  with  the  inferior 
vena  cava  and  extending  downward  to  one  or  both  femoral  veins,  causing 
the  usual  form  of  phlegmasia  alba  dolens. 

These  infected  thrombi  may  soften,  break  down  and  be  carried  to 
almost  any  part  of  the  body  as  the  liver,  lungs,  spleen,  the  heart,  the 
different  joints,  etc.    This  is  the  pathological  condition  in  that  form  of 


820  PUERPERAL  INFECTION 

puerperal  infection  called  pyemia,  in  which  repeated  rigors  with  sudden 
rises  of  temperature,  indicate  extension  of  portions  of  thrombi  or  colonies 
of  bacteria  to  organs  or  tissues,  as  distinguished  from  the  lymphatic 
variety  of  infection  already  described.  The  thrombophlebitic  form  is 
usually  less  often  fatal  and  less  rapid  when  it  is  fatal.  The  evidences  of 
infection  in  the  uterus  will  often  almost  disappear  and  that  organ  undergo 
a  fair  amount  of  involution  and  still  the  patient  continue  her  rigors  and 
wide  excursions  of  temperature  from  repeated  extensions  of  portions  of 
infected  thrombi,  perhaps  from  secondary  foci.  The  lungs  are  frequently 
the  seat  of  these  septic  emboli  and  a  sudden  pain  in  the  chest  and  the 
signs  of  a  localized  pleurisy  mark  the  event.  Not  infreciuently  the 
different  joints  of  the  body  are  involved  in  this  embolic  process  and 
the  writer  remembers  distinctly  one  of  his  patients  in  whom  almost  all 
the  joints  of  her  body  were  involved,  including  those  of  the  fingers  and 
even  one  temperomaxillary  articidation.  These  multiple  foci  of  infec- 
tion do  not  necessarily  mean  that  the  case  is  to  prove  fatal,  as  not  infre- 
quently they  gradually  lose  their  \irulence  and  complete  recovery  ensues, 
as  in  the  author's  case  just  referred  to.  The  process  is  often  a  long  one, 
and  the  patient  may  die  of  exhaustion,  associated  with  the  frequent 
rigors  and  protracted  fever  for  weeks  or  even  months,  but  the  farther 
removed  the  patient  is  from  the  date  of  confinement  and  infection,  the 
greater  the  chance  of  the  infection  losing  its  virulence  and  the  patient 
recovering.  The  possibility  of  an  embolus  plugging  one  of  the  large 
pulmonary  arteries  and  causing  sudden  death  must  always  be  considered. 

The  lodgement  of  a  portion  of  an  infected  thrombus  in  any  tissue  or 
organ  may  lead  to  the  formation  of  an  abscess  which  indicates  surgical 
interference,  and  until  this  pus  can  be  reached  and  evacuated  the  tem- 
perature will  continue.  ^Moreover,  this  may  be  only  one  of  many  foci 
of  pus.  and  the  hope  that  the  evacuation  of  this  will  cause  an  end  of  the 
fever  may  be  false. 

Phlegmasia  Alba  Dolens. — The  fact  that  the  lower  extremity  or  extre- 
mities after  confinement  occasionally  became  swollen,  painful,  white 
and  hard;  that  this  was  usually  associated  with  fever,  and  that  the 
secretion  of  milk  was  sometimes  diminished,  led  the  ancients  to  explain 
the  condition  as  a  metastasis  of  the  milk  and  to  call  it  "  milk-leg."  These 
views  are  now  known  to  be  erroneous,  yet  considerable  confusion  still 
surrounds  the  condition. 

It  is  now  known  that  it  is  not  necessarily  associated  with  parturition, 
that  pelvic  operations,  especially  hysterectomies,  are  not  infrequently 
followed  by  a  so-called  "milk-leg.  " 

^Moreover,  its  occurrence  is  not  limited  to  the  female  sex,  as  many 
men  recover  from  an  attack  of  typhoid  fever  with  one  or  both  lower 
extremities  in  this  condition. 

Varieties. — Two  varieties  may  well  be  recognized:  (a)  The  ])rimary, 
and  {b)  the  secondary.  In  each  variety  a  thrombophlebitis  is  the  under- 
lying cause. 

In  the  first  or  usual  variety  the  thrombophlebitis  is  the  primary  con- 
dition.   In  the  second  or  unusual  form  the  thrombophlebitis  is  secondary 


ESIONS  AND  PHYSICAL  SIGNS  OF  PUERPERAL  INFECTION      821 

to  a  pelvic  cellulitis,  the  result  of  infection  carried  from  the  parturient 
canal  by  the  lymphatics  to  the  cellular  tissue  of  the  pelvis,  thence  to 
•  the  cellular  tissue  of  the  thigh,  thence  to  the  crural  vein.  In  the  first 
or  primary  variety,  the  swelling  begins  at  the  foot  and  extends  upward 
as  the  return  blood  flow  is  empeded.  In  the  second  variety  the  swelling 
begins  in  the  thigh  and  the  foot  only  becomes  swollen  after  the  inflam- 
mation of  the  cellular  tissue  has  reached  the  vein. 

Etiology. — ^The  origin  of  the  second  or  cellulitic  variety  has  already 
been  discussed  when  studying  the  spread  of  infection  through  the  lym- 
phatics to  the  cellular  tissue  of  the  pelvis.  The  etiology  of  the  usual  or 
primary  variety  of  "milk-leg"  has  been  somewhat  obscured  by  the 
fact  that  it  has  often  followed  an  operation  or  confinement  from  which 
the  convalescence  for  the  first  and  perhaps  the  second  week  has  been 
afebrile,  and  thus  it  has  been  difficult  to  assign  it  to  infection.  Hence 
it  has  been  assigned  to  the  stasis  of  blood  in  the  pelvic  veins  from  the 
pressure  of  the  pregnant  uterus,  to  the  recumbent  posture  after  confine- 
ment or  operation,  to  the  condition  of  the  blood  in  pregnancy,  etc. 

The  author  believes  that  the  ordinary  condition  of  "milk-leg"  should 
be  looked  upon  and  called  a  thrombophlebitis,  and  that  in  most,  if  not 
all  cases,  it  is  due  to  an  infection;  this  infection  in  most  cases  being 
due  to  organisms  of  low  virulence,  perhaps  even  in  some  cases  to  sapro- 
phytic organisms.  In  this  belief  he  has  been  confirmed  by  his  experience 
in  many  cases  of  which  the  following  is  a  good  example : 

A  primipara,  on  the  evening  of  the  twentieth  day  of  a  normal,  afebrile 
puerperium,  had  a  slight  rigor,  and  a  rise  of  temperature  to  101°  F. 
The  next  morning  she  complained  of  pain  in  her  left  groin  and  palpation 
elicited  tenderness  along  the  left  femoral  vein.  That  day  the  foot,  leg 
and  thigh  became  swollen  and  she  ran  the  typical  course  of  a  thrombo- 
phlebitis. On  the  evening  following  the  onset  of  the  rise  of  temperature 
the  nurse  found  on  the  vulva  pad  a  small  piece  of  membrane  about  the 
size  of  a  thumb  nail,  which  was  distinctly  foul  in  odor.  The  foul  piece 
of  membrane  explained  to  the  author  the  thrombophlebitis  which  other- 
wise, on  account  of  her  twenty  days  of  afebrile  puerperium,  he  would 
have  been  unable  to  explain.  In  this  case  the  membranes  had  been 
unusually  adherent,  he  had  been  obliged  to  remove  them  manually  and 
had  done  so  as  thoroughly  as  possible,  but  evidently  this  little  piece  had 
resisted  his  efforts.  It  had  been  so  firmly  adherent  as  to  retain  its  vitality 
during  the  first  and  second  week  of  the  puerperium  and  only  during 
the  latter  part  of  the  third  week  had  it  fallen  a  prey  to  the  saprophytes 
and  become  necrotic. 

Clinical  Picture. — The  ordinary  thrombophlebitis  of  the  puerperium, 
as  a  rule,  occurs  during  the  second  or  third  week  after  confinement, 
and  not  during  the  first  week,  although  occasional  exceptions  occur. 
It  may  be  localized,  involving  a  group  of  dilated  veins  in  the  calf  or  in 
the  popliteal  space,  but,  as  a  rule,  involves  the  large  branches  of  the 
femoral  or  the  femoral  vein  itself.  The  attack  is  usually  ushered  in  with 
chilly  sensations  and  a  rise  of  temperature  (100°  to  101°  F.),  although 
both  of  these  may  be  slight.     There  is  usually  pain  in  the  groin  or  in  the 


822  PUERPERAL  INFECTION 

iiroul)  of  dilated  veins  to  he  iiivoK cd.  before  any  swelling  of  the  limb  can 
be  detected.  Within  a  few  hours,  however,  the  foot,  leg  and  thigh  become 
swollen  in  this  order  and  with  varying  <k'grees,  de])ending  ui)on  the  size 
of  the  vein  or  veins  occluded.  Paljiation  will  usually  detect  the  hardened, 
tender  vessel  whose  course  is  often  outlined  by  the  redness  of  the  skin 
over  it.  The  affected  limb  usually  feels  extremely  heavy  and  helpless 
to  the  patient,  while  to  the  observer  it  looks  whitish,  perhaps  mottled 
in  places  and  on  palpation  the  skin  feels  tense.  The  limb  is  painful  and 
the  most  comfortable  position  is  usually  that  of  outward  rotation  with 
knee  flexed. 

The  rise  of  temperature  and  pulse  usually  continue  for  about  a 
week. 

The  tenderness  ar.d  swelling  gradually  subside,  but  instead  of  the 
convalescence  being  completed  in  four  weeks,  as  is  the  rule  in  the  normal 
puerperium,  it  is  often  postponed  two  or  three  weeks  by  this  complica- 
tion, and  the  patient  for  a  year  or  longer  may  be  annoyed  by  swelling 
of  the  affected  limb  on  standing  or  much  walking.  In  fact,  in  some 
instances  the  venous  return  in  the  affected  limb  never  becomes  normal. 
Moreover,  one  of  the  disappointments  in  thrombophlebitis  of  the  lower 
extremities  is  that  sometimes,  just  as  the  condition  seems  to  be  sub- 
siding in  one  limb  and  the  temperature  and  pulse  have  reached  normal, 
the  other  limb  becomes  affected,  and  the  period  of  discomfort  has  to  be 
repeated  with  the  corresponding  interference  with  venous  return. 

Prognosis. — In  the  ordinary  form  of  thrombophlebitis  of  the  thigh 
or  leg,  or  both,  coming  on  in  the  second  or  third  week  of  the  puerperium, 
the  prognosis  is  usually  good.  The  convalescence  may  be  tedious  and 
the  leg  swell,  on  standing,  for  many  months,  and  as  already  stated, 
both  limbs  may  be  in^•olved,  yet  a  hopeful  prognosis  can  usually  be 
given.  The  possibility  of  a  pulmonary  embolus  must  always  be  thought 
of,  although  in  an  active  obstetric  experience  of  over  twenty-five  years  it 
has  never  been  the  author's  misfortune  to  meet  with  this  accident  in  a 
case  of  thrombophlebitis  of  the  thigh  or  leg.  He  has  lost  a  number  of 
cases  from  pulmonary  emboli  following  operation  or  delivery,  but  they 
have  always  occurred  in  cases  without  evident  thrombophlebitis  of  the 
thigh  or  leg.  In  a  series  of  20,000  consecutive  deliveries  at  the  Sloane 
Hospital  there  were  95  cases  of  phlebitis,  and  among  this  number  the 
only  death  from  pulmonary  embolus  was  one  who  started  to  leave  the 
hospital  contrary  to  advice  and  dropped  dead  in  the  hall. 

Diagnosis  of  Puerperal  Infection. — If  a  woman  after  delivery  has  a 
rise  of  temperature,  always  suspect  infection.  It  may  not  be  a  uterine 
infection;  it  may  not  be  an  infection  in  which  the  obstetrician  is  at  all 
at  fault;  yet  until  the  contrary  can  be  proved,  the  only  safe  rule  is  for 
the  obstetrician  in  his  own  mind  Che  need  not  impart  this  information 
to  the  family)  to  regard  the  temperature  as  evidence  of  infection,  and 
yet  for  his  own  peace  of  mind  he  should  endeavor  to  exclude  it.  Not 
infrequently  in  the  first  twelve  hours  following  a  long,  dry  labor,  the 
patient  will  have  a  slight  rise  of  temperature,  perhaps  between  100°  F., 
and  101°  F.,  corresponding  to  that  following  a  surgical  operation  in 


DIAGNOSIS  OF  PUERPERAL  INFECTION  823 

which  there  has  been  considerable  bruising  of  tissue.  This  for  lack  of  a 
better  term  is  usually  called  "  reactionary"  temperature,  and  is  character- 
ized by  the  fact  that  within  twenty-four  hours  the  temperature  falls 
to  normal  and  remains  there. 

Milk  Fever. — For  many  years,  on  account  of  the  fact  that  associated 
with  the  temperature  of  puerperal  infection  there  was  a  diminution  of 
the  milk  secretion,  the  condition  was  considered  in  some  way  due  to  a 
metastasis  of  the  milk  and  the  fever  was  called  "milk  fever."  With 
clearer  views  regarding  the  etiology  of  puerperal  infection  the  old  view 
of  its  being  due  to  the  milk  was  abandoned.  Xo  one  with  a  large 
experience  in  hospital  and  private  obstetrics,  however,  can  overlook  the 
fact  that  in  certain  women,  especially  nervous  primiparse  with  sensitive 
breasts  and  sensitive  nipples,  the  first  engorgement  of  the  breasts  is 
not  infrequently  accompanied  by  a  slight  rise  of  temperature  100°  F.  to 
101°  F.,  which  subsides  as  soon  as  the  breasts  soften  and  lactation  is 
well  established. 

Bowels. — Not  infrequently  the  intestinal  canal  of  the  parturient  woman 
is  far  from  empty  and  she  is  suifering  from  an  intestinal  auto-intoxica- 
tion which  may  cause  a  slight  rise  of  temperature,  subsiding  as  the 
intestinal  canal  is  emptied.  A  fall  of  temperature  to  normal  will  often 
be  noted  after  a  saline  or  other  cathartic  has  acted  well  on  the  third  or 
fourth  day,  and  the  result  may  be  due  to  one  or  all  three  of  the  following 
actions:  The  cathartic  relieves  the  congestion  of  the  breasts;  it  empties 
the  intestinal  canal  and  in  the  act  of  moving  the  bowels  the  uterus  is 
more  or  less  compressed  and  expulsion  of  lochia  or  clots  is  favored. 

Pyelitis. — One  of  the  unusual  complications  of  the  puerperium,  yet 
far  less  rare  than  formerly  supposed,  is  a  pyelitis  usually  the  result  of  a 
colon  bacillus  infection,  as  was  discussed  in  Chapter  XVIII.  This  usually 
causes  a  rise  of  temperature  which  would  be  confused  with  that  of 
uterine  infection,  unless  the  possibility  of  its  occurrence  be  kept  in  mind, 
and  by  finding  the  acid,  purulent  urine  and  the  enlarged  tender  kidney, 
its  presence  be  verified. 

Appendicitis ;  Twist  in  the  Fallopian  Tube  or  in  the  Pedicle  of  an  Ovarian 
Cyst  or  Fibromyoma ;  Sloughing  of  an  Ovarian  or  Uterine  Tumor,  etc. — The 
fact  that  a  woman  has  recently  been  delivered  does  not  signify  that  she 
is  exempt  from  abdominal  lesions  or  complications  from  which  she 
might  suffer  were  she  in  the  non-puerperal  condition.  In  fact,  she  is 
distinctly  more  liable  to  the  complications  mentioned  above  on  account 
of  the  change  in  relations  and  the  trauma  incident  to  the  delivery.  Thus, 
a  chronic  appendicitis  as  a  result  of  the  trauma  of  labor  may  become 
acute,  give  a  rise  of  temperature,  and  require  operation  in  the  first  few 
days  of  the  puerperium,  as  occurred  in  a  case  operated  on  by  the  author 
on  the  third  day. 

The  sudden  decrease  in  the  size  of  the  uterus,  with  the  increased  room 
in  the  abdomen  and  pelvis,  favors  a  twist  in  the  Fallopian  tube  or  in  the 
pedicle  of  any  ovarian  or  pendunculated  uterine  tumor.  Furthermore, 
the  trauma  of  labor  not  infrequently  causes  sloughing  in  an  ovarian 
dermoid  or  a  uterine  fibroid,  and  these  as  well  as  other  abdominal  and 


824  PUERPERAL  INFECTION 

peh  ic  complications  cause  a  rise  of  temi)tTature  which  might  lead  one 
to  (liaijnose  uterine  infection  unless  careful  diagnosis  was  always  sought. 

Having  excluded  the  breasts,  the  bowels,  the  kidneys  and  affections 
of  other  abdominal  or  pelvic  organs  as  the  cause  of  the  temperature  in 
the  case  at  hand,  the  obstetrician  is  forced  to  revert  to  his  first  suspicion, 
that  there  is  infection  of  the  parturient  canal.  The  question  now  pre- 
senting is:    Is  she  suffering  from  a  sapremia  or  a  bacteremia? 

In  an  ordinary  sapremia  there  is  organic  decomposing  material  within 
the  uterus.  It  may  be  there  in  the  form  of  a  portion  of  the  placenta  or 
blood-clots,  which  should  have  been  expelled  at  the  time  of  labor,  but 
were  not,  or  it  may  be  there  in  the  form  of  lochia,  which  should  have 
drained  away,  but  was  prevented  by  a  stenosis  of  the  internal  os  caused 
by  a  flexion  of  the  uterus  usually  anterior,  sometimes  posterior,  not 
infrequently  a  return  of  an  anteflexion  which  existed  before  pregnancy 
occurred. 

This  anteflexion  of  the  uterus  with  retained  lochia  and  rise  of  tempera- 
ture is  often  found  to  occur  when  the  patient  is  first  allowed  to  sit  out 
of.  bed.  These  cases  of  sapremia  are  those  in  which  the  lochia  usually 
has  an  odor  as  a  result  of  the  action  of  the  saprophytes  or  the  colon 
bacilli,  and  inspection  of  the  vulva,  perineum,  etc.,  shows  no  necrotic 
membrane. 

In  a  bacteremia,  on  the  other  hand,  there  may  be  no  decomposing 
placenta  or  blood-clots  in  the  uterus,  which  may  be  empty,  save  for  a 
grayish,  necrotic  membrane  lining  its  cavity  and  covering  any  abrasion 
on  cervix,  vagina,  and  vulva.  The  infecting  organisms  in  this  case, 
overcoming  the  protective  zone  of  leukocytes,  have  passed  through  the 
wall  of  the  parturient  canal  into  the  general  system.  The  lochia  is 
usually  scant,  perhaps  absent,  and  is  often  without  offensive  odor. 

Symptoms. — As  already  indicated,  the  one  predominent  symptom  of 
puerperal  infection  is  a  rise  of  temperature  usually  occurring  on  the  third 
or  fourth  day  of  the  puerperium,  perhaps  ushered  in  with  a  rigor  or  with 
chilly  sensations. 

This  may  be  given  as  the  general  rule,  yet  marked  variations  occur. 
In  some  cases  of  bacteremia  such  virulent  streptococci  are  introduced 
during  the  labor  that  the  temperature  rises  immediately  afterward  and 
remains  high  until  death  or  through  a  long,  tedious  convalescence.  On 
the  other  hand,  the  infection  with  rise  of  temperature  may  start  as  a 
sapremia  as  late  as  the  third  day,  and  this  in  turn  be  the  starting-point 
of  a  long  bacteremia. 

The  temperature,  as  a  rule,  is  higher  in  the  evening  than  in  the  morning, 
and  usually  takes  two  or  three  days  to  reach  its  highest  point.  In  the 
pyemic  variety  of  infection  the  rigors  are  frequently  repeated  and  the 
rises  and  falls  of  temperature  are  very  sudden  and  pronounced,  a  normal 
temperature,  a  rigor  and  a  temperature  of  105°,  all  occurring  perhaps 
within  a  space  of  two  or  three  hours. 

In  a  sapremia  the  pulse,  as  a  rule,  is  slow,  usually  below  100  unless  the 
condition  is  grave.  On  the  other  hand,  in  a  bacteremia  the  pulse  soon 
rises  to  120,  and  if  the  infection  is  severe  and  prolonged,  often  ranges 


TREATMENT  OF  PUERPERAL  INFECTION  825 

between  120  and  140  for  weeks.  The  nteriis  is  usually  subinvoluted  and 
tender.  The  character  of  the  lochia  has  already  been  described,  being 
usually  foul  and  abundant  in  a  sapremia;  scanty  or  absent  and  often 
without  odor  in  a  bacteremia. 

Inspection  of  lesions  along  the  parturient  canal  in  a  bacteremia  shows 
the  membranous  covering  due  to  superficial  necrosis.  The  condition  of 
the  abdomen  in  a  bacteremia  depends  upon  whether  the  infection  has 
spread  by  the  lymphatics  to  the  peritoneum  or  not.  If  the  peritoneum 
is  not  involved,  the  abdomen  may  be  soft,  not  distended,  and  not  tender, 
although  the  patient  may  suffer  with  a  septic  diarrhea.  If  the  infection 
has  spread  to  the  peritoneum,  it  may  be  localized  about  the  uterus  and 
appendages  as  a  pelvic  peritonitis  secondary  to  a  salpingitis,  or  a 
cellulitis,  and  in  this  condition  recovery  may  take  place  either  with 
or  without  surgical  interference. 

On  the  other  hand,  the  peritonitis  may  be  general,  with  tense,  distended 
abdomen,  vomiting,  rapid  pulse,  and  evidences  of  great  physical  depres- 
sion, although  the  patient  may  retain  consciousness  till  the  end.  The 
temperature  in  these  cases  of  general  peritonitis  varies  greatly.  It  usually 
remains  high  throughout,  but  occasionally  the  temperature  continues 
low,  and  the  rapid,  thready  pulse,  the  dry,  brown  tongue,  and  physical 
depression  show  the  gravity  of  the  case. 

As  indicated  above,  the  prognosis  of  a  general  peritonitis  resulting 
from  puerperal  infection  is  usually  fatal,  whether  they  are  subjected  to 
operation  or  not.  As  a  rule  the  symptoms  of  general  peritonitis  do  not 
present  themselves  until  the  third  or  fourth  day,  and  the  fatal  issue 
usually  occurs  within  a  week  or  ten  da}'s.  Occasionally  the  general 
peritonitis  arises  from  an  extension  of  a  localized  peritonitis  or  from 
rupture  of  a  localized  collection  of  pus,  as  in  the  broad  ligament  or  tube, 
and  here  the  symptoms  of  peritonitis  develop  later. 

The  appetite  and  digestion  in  cases  of  bacteremia  are  often  markedly 
impaired  and  add  to  the  difficulty  of  supporting  the  patient. 

In  the  pyemic  variety  of  infection  the  sweating  after  the  rigors  is 
often  very  profuse,  and  adds  to  the  weakness  and  depression  of  the 
patient. 

The  amount  of  pain  in  puerperal  infection  varies  greatly.  It  is  often 
greatest  when  the  process  is  localized  in  the  pelvis  with  the  development 
of  a  salpingitis  or  a  cellulitis,  which  fills  more  or  less  of  the  pelvis  with 
exudate,  and  then  breaks  down  into  an  abscess.  In  these  cases  they 
often  suffer,  not  only  with  the  pain  of  the  localized  peritonitis,  but  from 
the  pressure  upon  the  nerves  leaving  the  pelvis  and  from  interference 
with  the  functions  of  the  bladder  and  bowel.  On  the  other  hand,  many 
cases  of  general  peritonitis  which  evidently  are  desperately  ill  and 
approaching  a  fatal  issue  may  say  that  they  feel  very  comfortable.  Many 
cases  of  bacteremia,  even  those  which  eventually  recover,  present  a 
mild  delirium  during  the  height  of  the  fever. 

Treatment. — Prophylaxis. — The  greatest  dread  of  every  obstetrician, 
is  the  occurrence  of  puerperal  infection  in  his  practice.     Furthermore, 
this  dread  is  intensified  by  the  education  of  the  laity  to  the  belief  that 


826  PUERPERAL  JXFECTIOX 

if  infection  occurs,  the  obstetrician  or  tlic  nurse,  especially  the  former, 
is  at  fault. 

Tins  Ix-licf  nui\  he  unjust,  hut  it  exists,  and  the  knowledge  of  it  inten- 
sifies the  anxious  days  and  sleepless  nights  of  the  obstetrician  who  is 
unfortunate  enough  to  have  a  patient  whom  he  has  delivered  become 
infected. 

Such  being  the  case,  it  is  evident  that  prophylaxis  against  infection  is 
the  most  important  factor  in  the  treatment.  The  use  of  sterile  gloves 
in  the  conduct  of  a  delivery  has  already  been  referred  to  and  may  well 
be  emphasized  here.  No  practitioner  at  the  present  day  can  afford 
to  deliver  a  case  without  all  the  precautions  known  by  the  laity  to  be 
considered  valuable  as  prophylactic  measures  against  infection.  Sterile 
rubber  gloves  are  among  those  precautions  so  recognized,  and  if  a  case 
of  infection  occurs  and  gloves  have  not  been  worn,  the  obstetrician  is 
naturally,  and  probably  justly,  criticised.  Furthermore,  if  all  known 
precautions  have  been  used  and  infection  does  occur,  the  profession  as 
a  whole  will  stand  by  the  unfortunate  obstetrician.  Without  them  he 
forfeits  the  support  of  the  laity  and  the  profession  as  well. 

The  use  of  sterile  gloves,  however,  must  not  blind  the  obstetrician  to 
the  need  of  strictest  cleanliness  of  his  hands  within  the  gloves,  of  his 
person,  of  the  nurse,  the  field  of  operation,  and  the  drapery  of  this  field. 

The  hands  should  be  scrubbed  and  disinfected  as  thoroughly  as  though 
the  gloves  were  not  to  be  worn,  and  in  putting  on  the  gloves  their  exterior 
must  not  touch  the  ungloved  hand.  Furthermore,  the  outside  of  the 
gloves  must  not  touch  anything  unsterile,  else  their  sterility  is  destroyed. 

The  precautions  to  be  used  in  the  conduct  of  a  delivery  with  the 
preparation  of  the  patient's  vulva  and  draping  of  the  surrounding  field 
have  all  been  described  in  the  chapter  discussing  the  management  of 
normal  labor  (page  311),  and  will  now  only  be  referred  to.  The  reasons 
for  avoiding  the  antepartum  douche  as  not  only  unnecessary,  but  not 
devoid  of  danger,  were  there  set  forth.  The  prophylactic  measures  which 
the  author  would  here  summarize  and  emphasize  are  as  follows: 

During  her  pregnancy  keep  the  patient  in  the  best  possible  physical 
condition,  with  plenty  of  fresh  air  and  moderate  exercise.  Favor  her 
elimination  by  liberal  draughts  of  water  and  keep  her  bowels  free,  so  as 
to  avoid  auto-intoxication.  Have  the  confinement  chamber  well  lighted 
and  well  aired.  Have  the  nurse  wear  a  freshly  laundered  suit,  and  prepare 
herself,  including  the  scrubbing  and  disinfection  of  hands  and  forearms, 
as  for  a  surgical  operation.  Let  the  obstetrician  by  external  palpation 
and  auscultation  inform  himself  as  thoroughly  as  possible  as  to  the  con- 
dition of  the  fetus  and  its  relation  to  the  parturient  canal,  so  that 
internal  examinations  may  be  as  few  as  possible.  Then  with  the  hands 
and  forearms  of  the  obstetrician  scrubbed  and  disinfected,  his  person  cov- 
ered with  a  sterile  gown  and  his  hands  with  sterile  gloves,  let  him  surround 
the  prepared  vulva  with  sterile  drapery,  preferably  with  sterile  stocking- 
drawers  covering  legs  and  thighs  and  a  sterile  towel  on  the  abdomen. 
Lastly,  let  him  remember  that  the  only  way  to  make  a  vaginal  examina- 
tion with  the  least  risk  of  carrying  infection  from  the  vulva  without  to 


TREATMENT  OF  PUERPERAL  INFECTION  827 

the  sterile  vagina  within,  is  to  separate  the  labia  with  the  fingers  of  one 
hand  and  carry  the. examining  fingers  directly  into  the  vagina  without 
touching  the  vulva. 

During  the  second  stage  of  labor  keep  the  vulva  covered  with  a  wet 
bichloride  towel  to  avoid  contact  with  the  patient's  fingers  or  other  non- 
sterile  objects.  In  the  conduct  of  the  third  stage,  wait  twenty  minutes 
before  expressing  the  placenta,  thus  allowing  time  for  the  uterus  to  con- 
tract and  the  placenta  to  separate.  After  expressing  the  placenta  and 
membranes,  examine  carefully  for  any  missing  portions,  and  if  any  part 
of  the  placenta  or  any  large  portion  of  the  membranes  is  missing,  making 
certain  that  the  forearm  is  thoroughly  clean  and  the  glove  sterile,  go 
into  the  uterus  carefully  with  gloved  hand  and  remove  the  missing 
secundines.  Use  a  postpartum  douche  only  for  hemorrhage  or  for  special 
indications,  as  for  washing  out  debris  or  clots.  Repair  all  perineal  tears 
of  1  cm.  or  over.  Do  not  examine  for  cervical  lacerations  or  repair 
them  unless  cervical  hemorrhage  occurs  or  uterine  rupture  is  suspected. 
Keep  the  vulva  covered  with  sterile  dressings  at  least  during  the  first 
week  of  the  puerperium.  Have  the  nurse  exercise  the  greatest  care  of 
the  vulva  during  the  voiding  of  the  urine  and  movement  of  the  bowels. 
The  details  of  these  different  procedures  will  be  found  in  the  chapter 
concerning  the  management  of  normal  labor. 

Curative  Treatment. — Opinions  differ  considerably  regarding  the 
details  of  the  treatment  of  puerperal  infection,  although  the  majority 
are  agreed  that  conservatism  should  be  the  keynote  of  the  treatment. 
It  is  well  established,  on  the  one  hand,  that  nature  with  her  leukocytes 
and  tissue  resistance  is  often  able  to  limit  and  overcome  the  invasion 
of  the  infective  organisms.  On  the  other  hand  it  is  proved  by  accumulat- 
ing experience  of  recent  years  that  misguided  attempts,  by  currettage 
and  other  surgical  procedures,  to  rid  the  parturient  canal  of  its  infection, 
have  many  times  broken  down  nature's  barriers  and  have  made  general 
an  infection  and  inflammation  which  otherwise  would  have  continued 
local.  The  conclusion  to  be  drawn  from  this  experience  should  be  that 
every  effort  should  be  directed  toward  aiding  nature  in  her  resistance 
to  the  infecting  bacteria  and  in  favoring  their  elimination,  and  every 
care  should  be  taken  not  to  handicap  her  by  lowering  the  resistance  of 
the  tissues  or  opening  new  avenues  of  infection. 

In  the  first  place,  on  the  occurrence  of  a  rise  of  temperature  after 
delivery,  the  question  should  be  asked.  Is  the  temperature  possibly  due 
to  something  outside  the  parturient  canal?  Are  the  breasts  distended? 
Are  the  bowels  constipated?  Is  the  urine  normal?  Do  not  feel  at  the 
first  rise  of  temperature  that  the  parturient  canal  must  be  invaded, 
although  note  at  once  the  size  of  the  uterus  and  the  amount  and  character 
of  the  lochia. 

If  there  is  any  suspicion  of  distended  breasts,  endeavor  to  empty  them 
by  massage,  extra  nursing  or  breast-pump,  and  move  the  bowels  well, 
preferably  with  a  saline.  If  the  involution  of  the  uterus  seems  tardy, 
put  an  ice-bag  on  the  fundus.  It  will  do  no  harm  to  wait  until  the 
following  day  to  watch  the  effect  of  these  procedures  upon  the  temperature. 


828  PUERPERAL  INFECTION 

In  the  iiieantinic,  if  the  locliia  is  scant,  ck'\  ation  of  the  head  of  tlie  hod 
will  often  favor  th(>  drainaije  from  the  ntenis.  If  the  nrine  contains  ])ns 
and  either  kidney,  especially  the  ri<;ht,  is  enlaru-ed  and  tender,  the  treat- 
ment of  pyelitis  is  indicated  (see  page  ()()3). 

On  the  following  day,  if  the  temperatnre  is  again  high  and  the  breasts, 
bowels  and  kidneys  have  been  excluded  as  factors  in  its  causation,  the 
parturient  canal  must  be  considered  the  source  of  the  trouble.  If  every 
precaution  of  cleanliness  of  obstetrician,  nurse,  vulva  and  dressings 
has  been  observed,  the  patient  is  probably  suffering  from  a  sapremia 
from  the  retention  of  blood-clots,  lochia,  or  some  adherent  secundines 
which  w'ere  accidentally  overlooked  at  the  delivery,  and  the  temperature  is 
due  to  the  action  of  sai)rophitic  organisms  on  this  retained  organic  material. 

On  account  of  the  risk  of  carrying  infection  from  the  vagina  into  the 
uterus  by  a  vaginal  douche  during  the  first  few  days  of  the  puerperium, 
it  is  the  custom  at  the  Sloane  Hospital  to  postpone  vaginal  douching 
until  the  first  five  days  of  the  puerperium  have  passed,  during  this  period 
relying  upon  posture  and  the  use  of  an  ice-bag  upon  the  fundus  to  favor 
drainage  from,  and  contraction  of,  the  uterus.  At  the  end  of  five  days, 
if  the  elevation  of  temperature  still  continues,  our  practice  is,  with 
strictest  precautions  as  to  hands,  douche  can,  douche  nozzle,  vulva, 
etc.,  to  give,  once  or  twice  a  day,  a  hot  (110°  F.)  vaginal  douche  of  two 
quarts  of  sterile  saline  solution,  hoping  thereby  to  stimulate  the  uterus 
to  expel  its  contents. 

After  one  or  two  days,  if  the  temperature  has  not  come  down  and 
remained  low  under  the  use  of  the  vaginal  douches,  w^e  prefer  to  give 
one  intra-uterine  sterile  saline  douche,  using  a  speculum  and  one  sterile 
douche  nozzle  to  wash  out  the  vagina,  and  another  sterile  double-current 
douche  nozzle  passed  directly  into  the  cervical  canal  without  touching 
vulva  or  vaginal  w^alls  to  w'ash  out  the  uterus,  being  careful  to  pass  the 
nozzle  very  gently,  so  as  not  to  injure  the  uterine  wall,  but  allow  the 
saline  solution  to  wash  away  any  loose  debris. 

If  nothing  comes  away  with  the  douche  and  the  uterine  cavity  seems 
empty,  the  uterus  is  thereafter  left  alone  and  all  attention  directed  to 
the  general  condition  of  the  patient.  On  the  other  hand,  if  considerable 
debris  comes  aw^ay  with  the  douche  solution  and  the  uterine  cavity  seems 
large,  we  believe  it  good  practice,  wdth  the  sterile-gloved  finger  and  the 
patient  under  anesthesia  if  necessary,  to  gently  explore  the  cavity  of 
the  uterus,  removing  any  retained  blood-clots  or  secundines  with  the 
least  possible  trauma  to  the  uterine  wall,  realizing  that  any  trauma  may 
lessen  nature's  resistance  to  infective  organisms  and  may  be  the  means 
of  converting  a  local  into  a  general  infection.  A  few  facts  based  on 
experience  deserve  consideration. 

No  good  and  possible  harm  results  from  a  uterine  douche  when  the 
douche  fluid  returns  clear. 

All  intra-uterine  douches  should  be  given  with  the  greatest  gentleness 
in  puerperal  infection  lest  a  sapremia  be  converted  into  a  bacteremia. 

In  a  sapremia  an  intra-uterine  douche  is  usually  of  great  value  when 
carefully  given. 


TREATMENT  OF  PUERPERAL  INFECTION  829 

In  a  bacteremia  it  is  capable  of  doing  harm.  Hence  when  used  it 
should  be  given  with  the  hope  that  the  condition  is  a  sapremia,  but  in  a 
way  which  would  do  the  least  harm  if  the  condition  should  prove  to  be 
one  of  bacteremia. 

The  question  often  presenting  itself  to  the  consulting  obstetrician 
when  called  to  see  a  case  of  puerperal  infection  is:  Should  the  uterus  be 
explored  or  douched,  or  left  alone?  Each  case  should  be  decided  upon 
its  own  merits.  In  many  instances  the  attending  physician  has  already 
entered  the  uterus  with  douche  nozzle  or  curette,  or  both,  and  here  the 
best  procedure  is  usually  to  leave  the  uterus  absolutely  alone,  to  favor 
drainage  by  posture  and  treat  the  general  condition  of  the  patient.  On 
the  other  hand,  if  the  uterus  is  large  and  the  lochia  free  and  foul,  a  gentle 
exploration  with  the  gloved  finger  to  make  sure  that  the  uterus  is  empty, 
is  believed  by  the  author  to  be  good  practice. 

When  discussing  the  diagnosis  of  puerperal  infection,  attention  was 
called  to  a  variety  of  sapremia  caused  by  a  stenosis  of  the  uterine  canal 
at  the  internal  os,  the  result  of  a  flexion  of  the  uterus  either  anteriorly 
or  posteriorly  (see  Figs.  496  and  497) .  This  flexion  occurring  before  the 
lochia  has  ceased,  causes  its  retention,  with  the  resulting  sapremia. 

In  many  instances,  as  in  those  occurring  when  the  patient  first  sits  up, 
the  tension  of  the  retained  lochia  overcomes  the  resistance  of  the  stenosis, 
drainage  is  again  established,  and  the  temperature  returns  to  normal 
and  no  treatment  is  needed.  In  other  cases  a  hot  vaginal  saline  douche 
is  needed  to  stimulate  the  uterus  to  expel  its  lochia.  In  a  few  cases  an 
intra-uterine  douche  both  for  the  dilatation  accompanying  the  introduc- 
tion of  the  nozzle  and  for  the  irrigation  of  the  uterine  cavity  gives  the 
best  results. 

Having  made  certain  that  the  uterine  cavity  is  free  from  decomposing 
material  the  next  problem  is  to  aid  nature  in  resisting  further  invasion 
of  the  infecting  organisms  and  in  overcoming  those  already  present. 
A  careful  blood  count  is  of  considerable  assistance  in  determining  the 
degree  of  the  infection  present  and  the  resistance  of  the  patient. 

A  blood  culture  is  of  interest  scientifically,  but  in  the  author's  experi- 
ence it  has  never  proved  of  great  practical  value,  as  in  many  cases  of 
known  bacteremia  the  laboratory  report  of  the  blood  culture  has  been 
negative,  and  in  other  cases  the  treatment  had  to  be  instituted  before 
the  report  could  be  obtained. 

The  experience  gained  in,  the  treatment  of  tuberculosis  by  fresh  air 
has  wisely  guided  obstetricians  of  late  in  the  treatment  of  puerperal 
infection,  and  every  well-appointed  maternity  hospital  has  its  roof 
garden  to  which  the  bed  of  the  septic  patient  may  be  moved  and  kept 
most  of  the  time.  Following  these  lines  in  private  practice,  opening 
wide  the  windows  and  allowing  plenty  of  light  and  air  have  become 
routine  procedures  in  the  treatment  of  puerperal  infection.  Realizing 
that  anything  which  will  improve  the  general  condition  of  the  patient 
and  will  increase  her  tissue  resistance  will  favor  convalescence,  nourish- 
ing, easily  digested  food  is  distinctly  indicated.  The  heart  is  often 
subjected  to  a  long,  tedious  strain  and  the  use  of  cardiac  stimulants. 


830  PUERPERAL  INFECTION 

he^'innin^f  with  small  doses,  is  usually  indicated  in  bacteremia  in  antici- 
pation of  a  cardiac  weakness. 

Alcohol  is  especially  well  borne  in  this  condition,  and  it  together  with 
strychnin  and  digitalis  forms  a  trio  any  one  or  all  of  which  may  be  used 
to  great  advantage  in  maintaining  the  strength  of  the  circulation. 

For  the  relief  of  the  patient  when  the  fever  is  high,  cold  sponging  is 
of  marked  value  and  will  often  promote  sleep  and  conserve  the  strength 
of  the  patient.  The  coal-tar  antipyretics  are  not  to  be  recommended, 
as  they  all  tend  to  depress  the  heart,  a  result  the  opposite  of  what  is 
desired. 

Saline  enemata,  left  to  be  absorbed  and  furnish  saline  solution  to  the 
body  tissues  often  seem  of  value.  Bosc  has  claimed  marked  benefit 
from  subcutaneous  injections  of  saline  solution. 

Occasionally  the  patient  suffers  from  a  septic  diarrhea  which  becomes 
exhausting  and  needs  control.  A  moderate  dose  of  castor  oil,  or  a  saline 
followed  h\  the  use  of  bismuth  with  or  without  opium,  usually  gives 
the  best  results.  If  the  infection  has  extended  beyond  the  uterus,  but 
is  localized,  as  in  the  cellular  tissue  of  the  pelvis,  or  in  the  Fallopian 
tubes,  the  best  treatment  seems  to  be  the  expectant,  keeping  the  patient 
quiet  with  an  ice-bag  over  the  abdomen,  emptying  the  bowels  with 
enemata,  and  watching  constantly  the  physical  signs  and  the  tempera- 
ture chart  for  evidences  of  pus  formation,  when  incision  will  be  indicated. 
If  symptoms  of  general  peritonitis  arise,  the  case  is  usually  hopeless, 
although  this  will  be  referred  to  again  under  the  surgical  treatment. 
The  intravenous  use  of  .silver  in  the  form  of  a  colloidal  salt — collargol — 
introduced  by  Oede,  in  ISQo,  met  with  an  enthusiastic  reception,  but 
soon  lost  favor.  The  silver  ointment,  called  Oede's  ointment,  has  been 
extensively  used  by  the  author,  and  although  he  has  never  seen  any 
harm  result  from  its  use,  its  benefit  was  very  doubtful.  In  a  few  cases 
it  has  seemed  to  increase  the  resistance  of  the  patient,  and  in  two  cases 
the  rigors  which  had  been  daily,  ceased  at  once  on  beginning  its  use. 
Whether  this  was  due  to  the  ungentum  Crede,  as  appeared,  he  was  unable 
from  this  small  series  to  prove.  In  this  connection  attention  may  well 
be  directed  to  the  fact  that  it  is  extremely  difficult  to  determine  in 
puerperal  infection  whether  a  sudden  improvement  in  the  symptoms  of 
the  patient  is  due  to  the  remedy  used  or  not.  The  course  of  the  flisease 
is  often  one  of  marked  surprises,  and  without  treatment  the  picture  of 
a  patient  with  high  temperature  and  apparently  seriously  ill  may  within 
twenty-four  hours  change  to  one  rapidly  convalescing. 

The  discovery  by  ^Nlarmorek  in  1895,  of  an  antistreptococcic  serum 
naturally  raised  the  hopes  of  obstetricians  that  at  last  a  means  for  deal- 
ing successfully  with  puerperal  infection  had  been  found.  They  were 
doomed  to  disap})ointment,  however,  and  after  a  careful  study  of  the 
literature  of  rei)orted  cases  treated  with  it,  a  committee  of  the  American 
Gynecological  Society,  in  1899,  was  obliged  to  re])()rt  that  there  was  no 
evidence  in  favor  of  its  therapeutic  value. 

During  the  last  few  years  the  author  has  .several  times  used  a  polyv- 
alent serum  prepared  by  the  New  York  Board  of  Health  under  the 


TREATMENT  OF  PUERPERAL  INFECTION  831 

direction  of  Prof.  ^Yilliam  H.  Park.  This  serum  is  obtained  from  horses 
which  have  been  injected  with  about  fifteen  to  twenty  different  strains 
of  streptococci  from  different  cases  of  puerperal  fever.  The  horses 
are  treated  for  about  six  months  and  then  bled  and  the  serum  concen- 
trated. He  regrets  to  say  that  he  has  been  unable  to  see  any  marked 
benefit  to  the  patient  from  either  the  subcutaneous  or  intravenous  use 
of  the  serum,  but  when  gauze  soaked  in  the  serum  has  been  applied  to  a 
sloughing  wound  of  the  parturient  canal,  the  wound  has  cleaned  and 
healing  has  progressed  more  rapidly  than  would  ordinarily  be  expected. 

Experimental  work  with  antistreptococcic  sera  has  shown  that  the  serum 
does  not  neutralize  the  toxins  nor  act  directly  upon  the  bacteria  as  do 
the  antidiphtheritic  and  antitetanic  sera,  but  simply  favors  phagocytosis, 
or  in  other  words,  increases  the  opsonic  index  of  the  patient.  Hence  the 
antistreptococcic  serum  would  theoretically  have  more  prophylactic 
than  curative  power.  The  use  of  sera  up  to  the  present  time,  however, 
has  resulted  in  so  little,  if  any,  benefit  to  the  patient,  that  until  a  more 
valuable  one  is  discovered  the  author  does  not  fell  like  recommending  them. 

The  success  of  Sir  Almroth  \Yright  in  the  treatment  of  staphylococcus 
and  gonococcus  infections  with  bacterial  vaccines  raised  the  hope  that 
a  successful  method  of  treating  puerperal  infection  was  near  at  hand, 
but  in  1910  a  committee  of  the  American  Gynecological  Society,  com- 
posed of  Williams  (chairman),  Xewell  and  the  author,  after  careful 
study  of  the  literature  of  reported  cases,  reached  the  conclusion  that  in 
acute  general  infection,  the  t^pe  of  puerperal  infection  in  which  help  is 
most  needed,  little  is  to  be  expected  from  bacterial  vaccines.  A  few, 
however,  still  have  faith  in  their  use  even  in  acute  infections,  but  the 
majority  of  the  profession  have  abandoned  them  in  these  conditions. 
The  most  hopeful  field  in  puerperal  infection  for  the  use  of  bacterial 
vaccines  is  in  the  staphylococcus  or  gonorrheal  infections  and  in  the 
colon  bacillus  infection  of  the  kidneys. 

As  a  rule  autogenous  vaccines,  i.  e.,  those  made  from  the  patient 
herself,  are  considered  preferable  to  stock  vaccines. 

Surgical  Treatment. — In  recent  years  there  has  been  much  discussion 
regarding  the  value  of  surgery  in  the  treatment  of  puerperal  infection. 

In  this  discussion  three  different  phases  and  results  of  infection  must 
be  considered. 

1.  A  localized  collection  of  pus. 

2.  A  bacteremia.  ■ 

3.  A  thrombophlebitis. 

And  three  t}^es  of  operation  must  be  discussed: 

1.  Incision  and  dramage  of  an  abscess. 

2.  Hysterectomy. 

3.  Ligation  and  excision  of  thrombosed  pelvic  veins. 

Localized  Collections  of  Pns. — ^The  profession  are  well  agreed  that  where 
the  infection  has  spread  through  the  lymphatics  to  the  subperitoneal, 
cellular  tissue  of  the  pelvis,  with  the  formation  of  an  abscess,  this  abscess 
should  be  opened  and  drained,  and  in  the  carrying  out  of  this  procedure, 
practical  experience  has  demonstrated  certain  facts. 


832  PUERPERAL  INFECTION 

It  is  always  wise  not  to  be  in  too  much  of  a  hurry  to  incise  masses  of 
exudate  in  the  pelvis.  Many  of  them  absorb  without  breaking  down 
into  pus,  and  incision  is  unnecessary.  Incision  into  these  hard  masses, 
before  softening  has  indicated  the  shortest  route  to  the  pus  focus,  is 
attended  with  greater  risk  to  the  pelvic  viscera,  and  may  open  fresh 
tissue  with  new  avenues  for  the  spread  of  infection. 

If  the  collection  of  pus  can  be  reached  by  a  vaginal  incision,  that  is 
the  jireferable  route  both  for  drainage  and  for  the  comfort  of  the  patient. 

When  softening  and  the  sense  of  fluctuation  are  detected,  incision  is 
indicated  at  once.  Distinct  pus  may  not  be  found.  It  may  only  be  a 
septic,  serous  exudate,  yet  the  drainage  of  this  collection  aids  nature  in 
getting  rid  of  the  infection  and  absorbing  the  exudate.  As  to  the  location 
of  the  vaginal  incision,  the  author  always  prefers  the  median  line  behind 
the  cervix.  From  this  opening,  with  the  finger  or  a  blunt-pointed  scis- 
sors, any  pus  collection  in  the  pouch  of  Douglas  or  in  either  broad  liga- 
ment can  be  reached.  Occasionally  the  cellular  tissue  between  the 
uterus  and  the  bladder  becomes  infected  and  leads  to  a  pus  collection 
which  burrows  down  alongside  of  the  urethra.  This  collection  may 
be  best  reached  by  an  incision  in  the  anterolateral  vaginal  wall  or  even 
in  one  labium. 

Occasionally  the  exudate  and  pus  collection  lifts  up  the  folds  of  the 
broad  ligament  on  one  side  or  the  other,  so  that  fluctuation  is  detected 
just  above  Poupart's  ligament.  These  collections  are  most  satisfactorily 
treated  by  a  posterior  vaginal  incision,  but  in  some  cases  it  is  advisable 
to  incise  both  above  and  below  and  establish  through-and-through 
drainage. 

If  the  collection  of  pus  is  in  one  of  the  Fallopian  tubes  or  in  one  of  the 
ovaries,  two  questions  present  themselves:  Should  operation  be  per- 
formed at  once  or  postponed?  If  the  pus  tube  or  ovarian  abscess  is  not 
in  contact  with  the  vaginal  fornix,  the  operation,  if  performed,  would 
have  to  be  abdominal,  and  there  are  several  objections  to  an  abdominal 
operation  for  a  pus  collection  in  the  first  fortnight  of  puerperal  infection, 
unless  it  is  imperative.  The  infective  organisms  are  still  virulent.  The 
uterus  is  still  large  and  it  is  harder  to  reach  either  tube  or  ovary  through 
a  small  incision.  The  operation  may  rupture  the  sac  and  spread  the 
infection  which  before  was  localized.  Later  the  tubal  or  ovarian  sac 
may  prolapse  to  the  pouch  of  Douglas,  become  adherent  to  the  vaginal 
fornix  and  as  a  temporary  procedure,  to  enable  the  patient  to  recover 
from  her  infection,  the  pus  sac  may  be  evacuated  through  the  vagina, 
leaving  the  more  radical  abdominal  operation  until  later,  when  the 
woman  is  in  better  condition  and  the  infective  organisms  less  virulent, 
and  it  may  be  stated  here  that  not  infrequently  no  subsequent  abdominal 
operation  is  needed. 

On  the  other  hand,  if  the  pus  collection  in  tube  or  ovary  remains  high 
and  the  infection  seems  to  be  increasing,  the  best  procedure  is  an  imme- 
diate abdominal  operation,  being  guided  l)y  the  same  general  considera- 
tions as  those  wdiich  govern  in  operating  in  a  case  of  acute  suppurative 
appendicitis,  i.  c,  a  woman  profoundly  septic  endures  a  severe  abdominal 


TREATMENT  OF  PUERPERAL  INFECTION  833 

operation  badly.  The  best  results  follow  a  quick  operation  with  the  least 
possible  trauma,  the  rule  being  to  get  in  quickly,  remove  the  infective 
focus  and  get  out  quickly.  The  general  surgical  principles  of  elevation 
of  the  trunk  for  pelvic  drainage,  saline  solution  per  rectum  by  repeated 
enemata  or  by  the  drop  method,  etc.,  should  be  applied. 

Hysterectomy. — The  question  of  whether  a  hysterectomy  will  benefit 
a  patient  suffering  from  puerperal  infection  is  a  most  important  one. 
The  author's  view  is  that  in  a  bacteremia  it  is  not  indicated.  To  be  of 
value  it  would  have  to  be  performed  so  early  that  it  would  be  impossible 
to  tell  whether  the  patient  would  recover  without  it  or  not,  and  without 
doubt  some  of  the  cases  reported  as  cures  by  this  operation  have  recovered 
in  spite  of  the  operation,  rather  than  because  of  it,  and  some  who  have 
died  would  have  recovered  if  not  operated  upon.  Furthermore,  if  this 
treatment  came  into  general  use  it  is  natural  to  believe  that  the  mor- 
tality of  the  operation  would  be  greater  than  that  of  the  bacteremia, 
to  say  nothing  of  the  unsexed  condition  of  the  patient  on  her  recovery. 

When  performed  as  a  last  resort  after  the  infection  has  spread  beyond 
the  uterus,  the  operation  is  worse  than  useless,  as  it  is  impossible  by  it 
to  get  beyond  the  infection  and  by  the  additional  shock  to  a  woman  in 
poor  surgical  condition  the  end  is  hastened. 

Is  hysterectomy  ever  indicated  in  puerperal  infection?  This  question 
the  author  would  answer  in  the  affirmative  and  as  follows:  When  the 
focus  is  located  in  the  uterus,  the  removal  of  the  uterus  may  be  the  means 
of  saving  the  patient's  life.  This  condition  may  arise  under  varied 
circumstances.  The  indication  may  arise  as  a  prophylactic  measure  in 
the  course  of  a  Cesarean  section,  in  a  case  where  the  membranes  have 
been  long  ruptured,  there  have  been  many  examinations,  with  uncertain 
aseptic  technic,  and  where  at  the  operation  the  amniotic  sac  arouses 
suspicion  of  a  sapremia. 

It  may  also  be  indicated  as  a  prophylactic  measure  in  a  case  of  rupture 
of  the  uterus  with  niuch  trauma  and  where  infection  is  reasonably  feared. 
A  fibromyoma  of  the  uterus,  as  a  result  of  the  traiuna  of  the  labor,  may 
undergo  sloughing,  and  while  in  some  cases  a  submucous  or  a  subperitoneal 
tumor  may  be  removed  and  the  uterus  left,  in  the  majority  of  cases,  a 
sloughing,  infected,  fibromyoma  complicating  the  puerperium  indicates 
a  hysterectomy. 

We  come  now  to  a  class  of  cases  of  puerperal  infection  in  which  one 
or  more  abscesses  have  developed  in  the  uterine  wall.  These  are  cases 
in  which  nature  has  been  able  to  localize  more  or  less  the  infection,  and 
a  certain  number  of  the  cases  will  recover  if  the  uterus  is  removed. 

These  conditions  are  usually  not  present,  at  least  not  diagnosed 
early  in  the  puerperium,  usually  not  until  after  the  tenth  day,  and  the 
later  in  the  puerperimn  the  operation,  the  better  the  prognosis,  as  the 
organisms  have  probably  lost  some  of  their  virulence  and  the  patient 
may  have  increased  her  resistance.  The  mortality  of  these  operations 
is  always  high. 

In  5  cases  the  author  lost  3;  and  yet  they  are  almost  hopeless  without 
operation.  Sampson  reports  good  results  from  opening  the  abdominal 
53 


834  PUERPERAL  INFECTION 

cavity,  incising  the  abscess  in  the  uterus  and  draining  through  the  abtlom- 
inal  incision.  Of  course  the  feasibiUty  of  this  method  depends  upon 
the  number  and  location  of  the  abscesses.  In  the  author's  cases  the 
abscesses  were  multiple  and  hysterectomy  seemed  the  only  rational 
procedure.  The  difficulty  lies  in  the  diagnosis  of  the  condition,  but  a 
tender  nodule  or  irregularity  in  the  uterine  wall  should  always  suggest 
it.  The  author's  rule  is  never  to  perform  a  hysterectomy  for  puerperal 
infection  unless  he  can  detect  evidences  of  localization  of  infection  in 
the  uterus  or  unless,  in  operating  for  localized  infection  close  to  the 
uterus,  hysterectomy  seems  the  only  way  of  securing  satisfactory  drain- 
age, as  for  instance,  where  both  appendages  are  the  seat  of  pus  collec- 
tions, are  adherent  and  have  to  be  removed,  and  a  hysterectomy  would 
not  only  remove  an  organ  which  might  be  a  source  of  trouble  and  of  no 
use  in  the  future,  but  would  secure  free  downward  drainage  for  a  ragged 
infected  area. 

Ligation  and  Excision  of  Thrombosed  Pelvic  Veins. — Stimulated  by  the 
success  achieved  by  the  aurists  in  the  ligation  and  excision  of  the  lateral 
sinus  in  cases  of  mastoiditis,  complicated  by  a  thrombophlebitis  of  the 
neighboring  veins,  obstetricians  naturally  directed  their  minds  to  the 
possibility  of  curing  cases  of  puerperal  infection  complicated  by  thrombo- 


-/^>...-'-:^;;^vv-- 


Fig.  499. — Case  of  l.'Mj_tLiLiiu:i  '\\itli  fij\er  fur  -ixtj  -fijur  da^  s.     liuL-uVLiy  without  operation. 

phlebitis  of  the  pelvic  veins  by  their  ligation  and  removal,  and  many 
operations  are  now  on  record  in  which  this  procedure  has  been  tried. 
Among  the  pioneers  in  this  line  of  work  may  be  mentioned  Freund, 
Trendelenburg,  Williams,  Vineburg  and  others.  At  present  the  opera- 
tion is  still  sub  ju dice  and  the  obstetric  profession  seems  loath  to  adopt 
it,  save  as  a  very  exceptional  procedure.  The  difficulty  in  diagnosing 
the  condition,  the  fact  that  many  recover  without  operation  and  that 
many  are  likely  to  be  killed  by  the  operation,  who  would  have  recovered 
without  it,  are  large  factors  in  deterring  one  from  performing  it. 

The  author  would  sum  up  his  views  regarding  radical  surgical  inter- 
vention in  puerperal  infection  as  follows:  He  does  not  believe  in  operat- 
ing unless  he  can  distinctly  detect  a  localized  result  of  the  infection  with 
probable  pus  collection.  In  general  suppurative  peritonitis  the  result 
of  puerperal  infection,  although  he  has  opened  the  abdomen  and  drained 
a  nimiber  of  cases,  he  has  never  succeeded  in  saving  one.  Nevertheless, 
as  the  case  is  usually  fatal  without  operation,  in  the  hope  that  the  case 
might  be  one  of  multiple  foci  of  localized  peritonitis,  rather  than  a  general 
involvement  of  the  peritoneum,  he  would  feel  that  under  certain 
conditions  abdominal  exploration  was  indicated. 

To  students  and  ])ractitioners  tempted  to  radical  operation  for  puer- 
peral infection,  the  author  would  like  to  present  for  constant  consid- 


TREATMENT  OF  PUERPERAL  INFECTION  835 

eration  the  following  chart  (see  Fig.  499)  of  one  of  his  patients,  already 
referred  to  as  having  almost  all  her  joints  involved,  and  who  had  a  tem- 
perature for  sixty-four  days,  but  who  finally  recovered  completely  without 
operation. 

]\Iany  of  these  desperately  ill  patients  will  recover  if  one  leaves  them 
alone,  aiding  but  not  handicapping  nature  in  her  efforts.  Furthermore, 
it  may  be  borne  in  mind  that  as  the  distance  from  the  confinement 
increases,  the.  virulence  of  the  infecting  organisms,  as  a  rule,  decreases. 
In  the  meantime  the  obstetrician  should  be  constantly  on  the  watch  for 
indications  for  surgical  intervention. 


CHAPTER  XXIX. 

INFANT  MORTALITY. 

Stillbirths. — So  much  time  and  thought  is  being  devoted  at  the 
present  time  to  the  prevention  of  infant  mortality  that  it  is  of  interest 
to  see  what  the  infant  mortaHty  associated  with  labor  and  the  puerperium 
in  a  well-regulated  hospital,  like  the  Sloane  Hospital  for  "Women,  really 
is.  ¥oT  this  purpose  the  record  of  10,000  births  from  ^Nlarch  12,  1908, 
to  October  30,  1913,  has  been  carefully  analyzed  with  the  results  given 
below.  The  early  cases  in  this  series  antedated  the  routine  subjection 
of  every  mother  having  a  stillbirth  to  the  Wassermann  test,  hence  the 
number  of  stillbirths  assigned  to  syphilis  is  probably  not  as  large  as 
will  be  found  in  the  next  10,000  births  at  the  Sloane  Hospital. 


ANALYSIS   OF    10,000   BIRTHS. 

March  12,  1908,  to  October  30,  1913. 

Number  of  stillbirths' 449 

Number  of  abortions^ 231 

Number  of  living  births 9320 

Total  number  of  births 10,000 

CAUSES   OF   DEATHS   IN    INFANTS   BORN   ALIVE. 


Number  of  deaths 

in  hospital. 

Cause  of  death. 

Premature 
births. 

At  term. 

Total  deaths. 

Under      Over 

thirteen  thirteen 

days.      days. 

Under      Over 

thirteen  thirteen 

days.       days. 

Under  '    Over 

thirteen  thirteen 

days.       days. 

Deaths 
at  all 
ages. 

Accidents  of  labor 

Congenital  syphilis 

Congenital  weakness        .... 
Congenital  malformations     . 
Miscellaneous 

1 

10 

136 

2 
10 

3 
23 

11 

32 
3 
9 
9 

81 

2 
3 
3 
4 
47 

33 
13 
145 
11 
91 

2 
6 

26 
4 

58 

35 
19 

171 
15 

149 

Grand  total 

159 

37 

134 

59 

293 

96 

389 

'  Stillbirth — from  twenty-seven  weeks  of  pregnancy  to  term.     Any  -v-iable  fetus  in  which 
respiration  was  not  established  whether  heart  action  persisted  or  not. 

-  Abortion — during  first  twenty-six  weeks  of  pregnancy.     Any  non-viable  fetus. 

Day  of  birth  is  counted  as  first  day  of  puerperium:  thus,  thirteenth  day  of  puerperium 
is  really  twelfth  daj'  postpartum. 
(836) 


INFANT  MORTALITY 


837 


MISCELLANEOUS   CAUSES   OF   DEATH   AND   AGE   AT   DEATH   IN   DAYS   OF 
INFANTS   BORN   PRE]\L4TURELY   AND   AT   TERM. 


Causes  of  death. 


Under,lto2:2  to3:3to6 
1  day.  I  days,  days.!  days. 


Asphyxia  of  the 
newborn : 
Premature  . 
At  term 

Total       .      . 

Atelectasis: 
Premature  . 
At  term 

Total       .      . 

Hemorrhage  of  the 
newborn : 
Premature  . 
At  term 


Total 


x.„».  •  '   Total        .,, 

n^rri  '7  to  13  13  to  20  20  to  27   1  week    „f/'   I  Grand 
^-elk        <i^ys.     days.       days.        to  1       °"if ;   total. 
^®®'^-  '  month.    *S®^-' 


8 

^ 

3 

1 

14 

7 

6 

i 

17 


4 

28 


32 


11 


Total        .      . 

8 

8 

2 

1 

3 

11 

Sepsis  of  the 
newborn: 
Premature  . 
At  term 

1 

..  ;    2 

2 

6 

3 

2 

11 

13 

Total        .      . 

2 

2 

6 

3 

2 

11          ..13 

Pneumonia:' 
Premature  . 
At  term 

2 

1           2 

1           8 

3 

11 

3 
14 

7 
26 

i 

1 
10            2    !      15 

41            2    1      54 

Total       .      . 

2 

..     !     2         10 

14 

17 

33 

1 

51            4          69 

Digestive  disturb- 

ances: 
Premature  . 
At  term       .      . 

::;::'  :: 

"2 

'i 

3 

1 

1 
3 

Total        .      . 

1 
■  ■  1  ■ " 

2 

1 

3 

1     .        4 

Erysipelas : 
Premature  . 
At  term 

1 

1 

1 
1 

1 
1 

Total       .      . 

2 

2 

•     !        2 

Accidental  deaths 
(overlying) : 
Premature  . 
At  term 

1 

•           ^ 

2 

2 

Total        .      . 

1 

1 

2 

2 

Undetermined : 
Premature  . 
At  term 

2 

2           3 

7 

1 

1 

8 

Total        .      . 

2          ..          2           3 

7 

1      1      .. 

1 

8 

1  with  pneumonia  are  classed  5  deaths  from  congestion  of  lungs  (1  at  eight  hours,  2  at  four  days,  1  at 
thirteen  days,  1  at  sixteen  days)  and  1  death  from  empyema  (at  eleven  days). 


838 


INFANT  MORTALITY 


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INFANT  MORTALITY 


839 


MISCELLANEOUS  CAUSES  OF  DEATH  AMONG  BABIES  BORN  PREMATURELY 

AND   AT   TERM. 


Causes  of  death. 


Number  of  deaths. 


In    pre- 
matures 


At  term.     Total 


Asphyxia  of  the  newborn 

Atelectasis 

Hemorrhage  of  the  newborn  . 
Sepsis  of  the  newborn 

Pneumonia 

Empyema 

Congestion  of  lungs 
Digestive  disturbances 

Erysipelas 

Accidental  deaths  (overlying) 
Undetermined 


Total 


Total  deaths  from  pulmonary  causes  (asphyxia  of  the  newborn, 
atelectasis,  empyema,  pneumonia,  and  congestion  of  lungs) 


15 


21 


19 


28 

11 

13 

48 

1 

5 

3 

1 

2 


128 


90 


8 

32 

11 

13 

63 

1 

5 

4 

2 

2 


149 


109 


INDEX. 


Abdomen,  pendulous,  624 

influence  of,  on  pregnancy,  693 
Abdominal  binder,  346 

cavity,  shortening  of,  625 
palpation  in  breech  presentations,  296 
in  L.  O.  A.  position,  255 
in  L.  O.  P.  position,  267 
in  L.  M.  A.  position,  281 
in  R.  M.  A.  position,  281 
in  R.  O.  A.  position,  256 
in  R.  O.  P.  position,  267 
pregnancy,  523,  525,  549 
wall,  inertia  of,  619 

lack  of  tone  in,  624 
Abortion,  506.     See  Miscarriage, 
accidental,  508 
after-treatment  of,  520 
complete,  508 
criminal,  508 
due  to  fibroids,  633 
etiology  of,  506 
frequency  of,  506 
habitual,  treatment  of,  520 
incomplete,  508 

treatment  of,  516 
induction  of,  732 

fetal  indications  for,  734 
maternal  indications  for,  732 
methods  of,  734 
technic  of,  735 
inevitable,  508 

treatment  of,  515 
intentional,  508 
medical,  508 

neglected,  treatment  of,  520 
pathology  of,  508 
prophylaxis  of,  513 
symptoms  of,  508 
threatened,  508 

treatment  of,  515 
treatment  of,  513 
tubal,  534 
Abscess  in  puerperal  infection,  831 
Accidental  abortion,  508 

hemorrhage,   574.     See  Hemorrhage, 
accidental. 
After-coming  head,  714 
delivery  of,  305 
forceps,  766 
After-pains,  371 

Air-embolism      complicating     pregnancy, 
468 


Albuminuric  retinitis,  479 

Alimentary    canal,    disorders    of,    during 

pregnancy,  481 
Allantois,  88,  97 
Amnion,  88,  92 

diseases  of,  500 
dropsy  of,  500 
Ampulla  of  breast,  51 
Amputations,  intra-uterine,  505 
Anal  fascia,  33 
Anemia  complicating  pregnancy,  469 

puerperium,  469 
Anencephalus,  702 
Anesthesia  during  second  stage  of  labor, 

321 
Anesthetics,    use    of,    in    eclampsia    and 

toxemia,  435 
Antepartum  examination,  169 
Anticolic  nipple,  404 
Appendicitis  complicating  pregnancy,  483 

in  puerperal  infection,  823 
Appetite  during  pregnancy,  132 
Areola  of  breast,  51 
primary,  127 
secondary,  131 
Argyrol  for  child's  eyes,  337 
Armamentarium,  obstetrician's,  165 
Arms,  extended,  in  breech  presentations, 

715 
Articulations,    changes    in,   during   preg- 
nancy, 139 
of  fetal  skull,  237 
pelvic,  abnormally  firm,  677 
loose,  678 
Artificial  feeding,  396 

respiration,  methods  of,  353 
Ascites  diagnosed  from  pregnancy,  147 
Asphyxia  livida,  352 
neonatorum,  351 

antepartum  diagnosis  of,  352 
clinical  picture  of,  352 
differential  diagnosis  of,  351 
etiology  of,  351 
treatment  of,  353 
pallida,  352 
Asthma  during  pregnancy,  462 
Atresia  of  cervix  uteri,  643 

of  vagina,  646 
Attitude  of  fetus,  243 
Auscultation  of  fetal  heart,  181 
in  breech  presentations,  296 
in  L.  M.  A.  position,  281 
in  L.  O.  A.  position,  257 
in  L.  O.  P.  position,  267 

(841) 


842 


INDEX 


Ausciilt;it  ion  ill  R.  M.  A.  i)()sitii>ii,  2S1 

in  R.  C).  A.  position,  257 

in  R.  ().  P.  position,  2(57 
Auto-infoftion,  possibility  of,  812 
Auto-intoxicatioM,  intestinal,  in  puerperal 

infection,  S'l'-\ 
Axillary  breast  tissue,  3S(i 
Axis-traction  forceps,  748,  758,  7()3,  764 


B 


Babies,    premature,    immediate   care   of, 
361 

undersized,  immediate  care  of,  361 
Baby,  bath  of,  348 

clothing  of,  346 
Bacillus  aerogenes  capsulatus  in  puerperal 
infection,  811 

coli  communis  in  puerperal  infection, 
811 

Klebs-Loeffler,  in  puerperal  infection, 
811 

typhosus  in  puerperal  infection,  811 
Bacteremia  in  puerperal  infection,  814,  816 
Bacteria  in  lochia,  374 

in  milk,  398 

destruction  of,  405 
Ballottement,  143 
Bartholin's  glands,  22 
Bath  of  baby,  348 
Bathing  during  pregnancy,  151 
Bed,  pre]iaration  of,  for  labor,  309 
Bimanual  examination  during  pregnancy, 

184 
Binder,  abdominal,  346 

breast,  385 
Birth,  changes  in  circulation  at,  114 
Bladder,  26 

calculi  in,  obstructing  labor,  642 

care  of,  during  pregnancy,  136 
in  puerperium,  376 
Blood  during  pregnancy,  132 
Blood-pressure    during    pregnancy,     133, 
135,  155 

in  eclampsia,  429 
Bones,  changes  in,  during  pregnancy,  139 
Bottles  for  milk,  404 
Bowels  during  puerperium,  375 

in  puerperal  infection,  823 

regulation  of,  during  pregnancy,  152 
Braxton  Hicks's  method  of  version,  770 
Breasts,  50,  379 

axillary  tissue  of,  386 

ampulla,  51 

areola,  51,  127,  131 

arterial  supply,  53 

binder  for,  385 

caked,  385 

care  of,  384 

changes  in,  during  pregnancy,  127 

during  pregnancy,  153 

galactophorous  ducts,  51 

lactiferous  ducts,  51 

lymphatics  of,  53 

Montgomery's  tubercles,  51 


Breasts,  nerve  supply  of,  53 
nipple,  51 
sinus,  51 

supernumerary,  52 
sj'mptoms  of  pregnancy,  141 
Breech  presentations,  247 

abnormalities  of,  711 
birth  of  head  in,  298 
of  hips  in,  297 
of  shoulders  in,  298 
complete,  247,  294 
descent  in,  297 
diagnosis  of,  296 
engagement  in,  297 
extended  arms  in,  713 
frank,  247,  294,  711 
forceps  delivery  in,  766 
frequencj^  of,  294 
incomplete,  247,  294 
internal  rotation  in,  297 
mechanism  of,  247,  297,  299,  301 
molding  in,  297 
normal,  247,  294 
positions  in,  250 
posterior  rotation  of  occiput  in, 

299 
prog-nosis  of,  301 
treatment  of,  302 
with    arms    abnormally    placed, 

713 
with  extended  legs,  247,  294,  711 
with  nuchal  hitch,  714 
Bregma  presentations,  294 
Broad  ligaments  of  uterus,  39 
Brow  presentations,   diagnosis  of,   291 
mechanism  of,  290,  291 
prognosis  of,  293 
treatment  of,  293 
Bulbi  vestibuli,  22 
Bulbocavernosus  muscle,  35 
Bulbs  of  vestibule,  22 
Byrd's  method    of    artificial    respiration, 
356 


Caked  breasts,  385 

Calculi,  vesical,  obstructing  labor,  642 

Caloric  value  of  food,  410 

Canal  of  Nuck,  39 

Cancer.    *See  Carcinoma. 

of  rectum,  dystocia  due  to,  642 

of  uterus  complicating  pregnane}^  639 

Caput  succedaneum,  365 

Carcinoma   of  cervix  complicating   preg- 
nancy, 450 

Cardiac  disease  during  pregnancy,  459 

Carriers  of  infection  in  puerperal  infection, 
811 

Carunculae  myrtiformes,  22 

Catheterization  during  puerperium,  376 

Cellulitis  in  puerperal  infection,  818 

Celom,  origin  of,  76 

Cephalhematoma,  366 

Cephalometry,  189,  190 

Certified  milk,  397 


INDEX 


843 


Cervix  uteri,  at  end  of  pregnancy,  231 
atresia  of,  643 

carcinoma  of,  complicating  preg- 
nancy, 450 
changes    in,    diu-ing   pregnane}^, 
125,  141,  142 
in  puerperium,  370 
conditions  causing  dj'stocia,  643 
edema  of  anterior  lip,  645 
incisions  in,  to  aid  labor,  782 
lacerations  of,  579,  723 
septa  of,  645 
stenosis  of,  643 
Cesarean  section,  787 

extraperitoneal,  796 

compared    with    Sanger's 

operation,  800 
technic  of,  796 
history  of,  788 
indications  for,  789 
mortaUty  of,  795 
Porro's  operation  for,  788 
postmortem,  800 
repeated,  795 
Sanger's  method  of,  788 
subsequent   care   of  patient   in, 

795 
technic  of,  791 
time  of  operation,  791 
vaginal,  783 

disadvantages  of,  786 
indications  for,  785 
technic  of,  784 
Chamberlen  forceps,  746,  747 
Child,  care  of,  in  abnormal  conditions,  351 
at  birth,  333 
length  of,  at  birth,  240 
Chloral  hydrate,  use  of,  in  eclampsia  and 

toxemia,  441 
Chloroform,  effects  of,  in  eclampsia  and 
toxemia,  435 
use  of,  in  labor,  322 
Cholera  comphcating  pregnane}-,  478 
Chorea  in  pregnancy,  45 
Chorio-epithehoma,  495 
clinical  picture  of,  498 
diagnosis  of,  500 
etiology  of,  497 
frequency  of,  497 
pathologj'  of,  497 
treatment  of,  500 
Chorion,  88,  90,  97,  98 
diseases  of,  491 
frondosima,  99 
villi,  100 
Circular  artery,  46 
Circulation,  changes  in,  at  birth,  114 

during  pregnane}-,  132 
Circumcision,  411 

Civilization,  relation  of,  to  labor,  5 
Cleavage,  67 
Chtoris,  19 
Clothing  of  baby,  346 
Coccygeus  muscle,  32 
Colostrum,  131,  380 
Columns  of  Morgagni,  29 


Columns  of  rectum,  29 
Compound  presentation,  716 
etiolog}-  of,  716 
frequency  of,  717 
mortalit}'  of,  717 
treatment  of,  717 
Condylomata     complicating     pregnane}-, 

449 
Confinement,  date  of  expected,  157 
Constipation  dm-ing  pregnancy,  152,  482 
Constrictor  vaginse  muscle,  35 
Contagious  diseases,  relation  of,  to  puer- 
peral infection,  813 
Contracted  pelves,  648,  692.    See  Pelves, 

deformed. 
Convalescence,  379 

Cord,  prolapse  of.    See  Prolapse  of  cord. 
Corpus  luteum,  61 
Cough,  reflex,  of  pregnancy,  463 
Cow's  milk,  396 

bacteria  in,  398 

certified,  397 

compared    with    woman's    milk, 

397 
from  herd,  397 
from  single  cow,  397 
home  modification  of,  398 
modification  of,  397,  398 
Coxalgic  pelvis,  690 
Coxitis,  690 
Cragin's  method  of  artificial  respiration, 

359 
Craniotomy,  801 

indications  for,  801 
instruments  needed  in,  802 
prognosis  of,  805 
technic  of,  804 
Cream,  399 

centrifugal,  399 
gravity,  399 
Crede's   method   of   expressing   placenta, 

217,  342 
Criminal  abortion,  508 
Crypts  of  Morgagni,  29 
Cyanosis  neonatorum,  116 
Cystocele  complicating  pregnancy,  449 


DiNIMERSCHLAF,   324 

Date  of  expected  confinement,  157 
Decapitation  of  fetus,  807 
Decidua,  97,  98 

atrophy  of,  489 

bacterial  inflammation  of,  489 

basalis,  98 

capsularis,  105 

diseases  of,  488 

hemorrhage  of,  490 

hyperplasia  of,  488,  489 

parietalis,  105 

reflexa,  105 
Deformed     pelves,     648.       See     Pelves, 

deformed. 
Delivery,  postmortem,  801 


844 


INDEX 


Delivery,  surgical  methods  of,  771) 
Dew's  method  of  artific^ial  respiration,  357 
Diabetes  during  pregnancy,  486 
Diagonal    conjugate,     measurements    of, 

185 
Diameters,  cephalic,  2;5S 
of  fetal  heail,  238 
of  j)elvis,  170,  17(1 
Diet  diu-ing  pregnancy,  150 
puerperium,  375 
effect  of,  on  mother's  milk,  393 
Digestion  during  pregnancy,  131 
Double  monsters,  703 

diagnosis  of,  704 
mechanism  of  labor,  705 
obliquely  contracted  ])elvis  of  Robert, 
662.     See  Pelves,  deforii^ed. 
Douches  in  puerperal  infection,  828 

vaginal,   during  pregnancy,    153 
Douglas,  pouch  of,  28,  38 
Draping  of  patient  for  second  stage  of 

labor,  320 
Dress  during  pregnancy,  150 
Drink  during  pregnancy,  150 
Dropsy  of  amnion,  500 
Dry  labor,  209 
Duct  of  Gartner,  45 

of  Miiller,  47 
Diihrssen's  incisions,  783 
Dysmenorrhea,     membranous,    diagnosed 

from  ectopic  gestation,  546 
Dystocia  from  conditions  of  cervix  uteri, 
643 
of  vagina,  646 
of  vulva,  (546 
from  kidney  affections,  642 


Ear,  affections  of,  complicating  pregnancy, 

480 
Eclampsia,  424 

anesthetics  in,  435 

blood-pressure  in,  429 

diagnosed  from  epilepsy,  432 
from  hysteria,  432 

differential  diagnosis  of,  431 

edema  in,  429 

etiology  of,  24 

eyes  in,  430 

frequency  of,  430 

liver  in,  424 

mortality  of,  fetal,  42 

nausea  in,  430 

nervous  system  in,  430 

pathology  of,  424 

prognosis  of,  441 

prophylaxis  of,  432 

seizure  in,  431 

symptoms  of,  429 


threatened,  424 
treatment  of,  432 
types  of,  431 
urine  in,  429 
vomiting  in,  430 


Eclamptic  seizure,  431 
Ectoderm,  derivatives  of,  79 
Ectojnc  gestation,  522 

abdominal,  523,  525,  549 
advanced,  549,  551 

diagnosis  of,  549,  551 
operation  for,  557 
treatment  of,  555 
bilateral  tubal,  530 
tliagnosed    from    membranous 
dysmenorrhea,  546 
from  miscarriage,  545 
from    rupturecl    i)yosalpinx, 
545 
diagnosis  of,  542 

differential,  545 
etiology  of,  526 
frequency  of,  522 
interstitial,  523,  525 
intraligamentous,  525,  549 
multiple,  530 

operation  for  advanced,  557 
ovarian,  522,  524 
pathology  of,  531 

changes  in   Fallopian  tube, 
532 
in  ovum,  538 
in  uterus,. 531 
])hysical    signs   of,  before   tubal 
rupture  or   abortion, 
543 
subsequent      to     tubal 
rupture   or   abortion, 
544 
placenta  in,  539 
primary,  525 
repeated,  530 
secondary",  525 
symptoms  of,  541 

at  time  of  tubal  rupture  or 

abortion,  542 
before     tubal     rupture     or 
abortion,  541 
treatment  of,  552 

advanced,  555,  557 
early,  552 

at  time  of  tubal  rupture 

or  abortion,  552 
prior  to   tubal  rupture 

or  abortion,  552 
subsequent     to     tubal 
rupture   or   abortion, 
555 
tubal,  523,  524,  525 
bilateral,  530 
twin,  530 
tubo-abdominal,  550 
tubo-ovarian,  524,  525 
tubo-uterine,  523,  525 
twin  tubal,  530 
varieties,  522 
Edema  of  anterior  lip  of  cervix  uteri,  645 
of    lower    extremities,     complicating 

pregnancy,  447 
in  pregnancy,  429 
of  vulva,  647 


INDEX 


845 


Edema  of  vulva,  complicating  pregnane}-, 

Elliot  forceps,  748,  751 
Embolism,    air,    complicating   pregnancy, 
468 
pulmonarj',   complicating  pregnancv, 
467 
puerperium,  467 
Embrj'o,  age  of.  119 

external  form  of,  116 
length  of,  119 
Embryology',  54 
Embryotomy,  806 

indications  for,  806 
instritments  needed  in^  806 
technic  of,  807 
Emphysema   during   pregnancy,   462 
Enceplialocele,  707 
Endometritis  decidua  cj-stica,  489 
poh'posa,  489 
-  tuberosa,  489 
Endometrium,  39 

changes  in,  in  puerperium,  369 
Enteroptosis,  dui-ing  pregnancy,  483 
Entoderm,  derivatives  of,  SO 
Epilepsy  diagnosed  from  eclampsia,  432 

dui-ing  pregnancy,  459 
Episiotomy,  330 
Epistaxis  dm-mg  pregnancy,  481 
Epoophoron,  44 
Erector  cUtoridis  muscle,  35 
Ether,  use  of,  in  eclampsia  and  toxemia, 

438 
Evolution,  spontaneous,  709 
Examination,  ahtepartmn,  169 

dm^ing  pregnane}-,  156,  158,  169 
bimanual,  184 
vaginal,  184 
of  patient  at  bedside,  vaginal,  313 
Exercise  diu-ing  pregnane}-,  151 
Expulsive  forceps,  deficiency  in,  610 
Extended  arms  in  breech  presentations, 

713 
Extraperitoneal  Cesarean  section,   796 
Extra-uterine   pregnancy,    522.     See   Ec- 
topic gestation. 
Eyes,    affections   of,    compUcating    preg- 
nancy, .  479 
of  child,  treatment  of,  337 


Face  presentations,  247 

diagnosed  from  breech  presenta- 
tions, 296 

etiolog}-  of.  279 

forceps  delivery  m,  764 

mechanism  of.  278.  281 

positions  in,  249,  280 
Fallopian  tubes.  40 

ampulla  of,  41 

arterial  supply  of,  46 

changes  in.  m  ectopic  gestation, 
532 

development  of,  47 


Fallopian  tubes,   fimbriated  extremitv  of, 
41 
infundibulimi  of,  41 
interstitial  portion  of,  40 
isthmus  of,  41 
mucous  coat  of,  41 
muscular  coat  of,  41 
nerve  supply  of,  47 
serous  coat  of,  41 
twist  in,  in  puerperal  infection, 
823 
Fascia,  33 

Fat  in  modified  milk,  398 
in  woman's  milk,  391 

.  estimation  of,  392 
Feeding,  artificial,  396 
mixed,  390 

of  prematm-e  infants,  408 
Femur,  dislocation  of,  aft'ecting  labor,  691 
Fertilization,  65 
Fetal  head,  234 

articulations  of,  237 
cncumferences  of,  239 
cranium  of,  235 
diameters  of,  238 
extension  of,  238 
face  of,  235 
fontanehes  of,  236 
measurements  of,  189,  190 
moldmg  of,  240 
motions  of,  238 
sutiu'es  of,  235 
heart,  auscultation  of,  181 

in  breech  presentations,  296 
in  L.  ]M.  A.  position,  281 
in  L.  0.  A.  position,  257 
in  L.  O.  P.  position,  267 
in  R.  M.  A.  position,  281 
in  E,.  O.  A.  position,  257 
in  R.  0.  P.  position,  267 
heart  soimds  dm-ing  pregnancy,  144 
membranes,  88 

diseases  of,  491 
in  man,  9 1 
movements  during  pregnancy,  144 
ovoid,  243 

skuU.     See  Fetal  head. 
Fetus,  234 

anomalies  of,  causing  abnormal  labor, 

697 
attitude  of,  243 
auscultation  of  heart  of,  181 
decapitation  of,  807 
external  tumors  of,  705 
heart  soimds  of,  182 
;  length  of,  240 

I  location  of  back  and  small  parts  of, 

I  1" 

I  malformations  of,  699 

overgi'Owi:h  of,  697 

dystocia  from,  705 

treatment  of,  698 
palpation  of,  180,  181 
papyraceous,  512 
positions  of,  177,  248 
presentations  of,  177,  244 


846 


INDEX 


Fetus,   presentations  of,    anterior   fonta- 
nelle,  29-1  __ 

breech,  2-47,  711 

bregma,  24(i.  2oO,  294 

brow,  2-4(),  250,  291 

cephalic,  244 

compound,  248,  716 

face,  247 

faulty,   influence  on  pregnancy, 
693 

elbow,  248 

foot,  247 

hand,  248 

knee,  247 

longitudinal,  244 

oblique,  244 

pelvic,  244 

shoulder,  248,  707 

transverse,  244,  247,  707 

in  twin  pregnancy,  196 

vertex,  245 
sjTjhilis  in,  evidences  of,  472 
vascular  system  of,  111 

changes  in,  at  birth,  114 
Fibroids.     See  Fibromyoma. 
abortion  due  to,  633 
changes  in,  631,  632 
complicating  labor,  630 
diagnosis  of,  035 
eflfects  of,  on  labor,  633 

on  pregnancy,  632 

on  puerperiiun,  634 
mortality,  635 
treatment,  636 
Fibroma  molluscum  in  pregnancy,  454 
Fibromyoma.     Sec  Fibroids, 
complicating  labor,  630 

pregnancy,  451 
diagnosed  from  pregnancy,  145 
in  puerperal  infection,  823 
Floor,  pelvic,  31 
Fontanelles  of  fetal  skull,  236 
Food,  caloric  value  of,  410 
commercial,  411 
does  it  agree  with  infant,  409 
.    preparation,  instruction  in,  402 
Forceps,  745 

application  of,  759 

cephalic,  759 

Continental  methoil,  759 

double,  702 

English  method,  759 

opI VIC    T  tO 
axis-traction,  748,  753,  763,  764 
choice  of,  751 
contra-indications,  754 
dangers  in  use  of,  755,  756 
double  application  of,  762 
frequency,  754 
function,  750 
historical  .sketcli  of,  745 
indications  for,  754 
introduction  of  blades,  7()0,  761 
locking  of  blades,  762 
mortality  in  use  of,  766 
position  of  patient,  757 


Forceps,  preparation  of  patient,  758 
removal  of  blades,  762 
steps  of  operation,  759 
technic  of  operation,  757 
traction  by,  762 

use  of,  for  after-coming  head,  766 
in  breech  presentations,  766 
in  face  presentations,  764 
in  occipitoposterior  positions  of 
vertex,  762 
varieties  of  operations,  756 
high,  756 
low,  756 
medium,  756 
Foreskin,  retraction  of,  411 
Fossa  navicularis,  18 
Fourchette,  18 
Frank  breech,  247,  294,  711 
Freeman's  apparatus  for  sterilization  of 

milk  by  pasteurization,  405 
Fresh  air  diu"ing  pregnancy,  152 


Gal.\ctophorous  ducts,  51 
Gall-bladder,  affections  of,   during  preg- 
nancy, 485 
Gall-stones,       complicating      pregnancy, 
485 

puerperium,  486 
Gartner,  duct  of,  45 
Gastric     indigestion    during     pregnancy, 

482 
Gastroptosis  during  pregnancy,  483 
Generalh^    contracted    pelvis,    655.     See 

Pelves,  deformed. 
Generative  organs,  anatomy  of,  17 

arterial  supply  of,  45 

external,  18 

internal,  36 

h-mphatics  of,  46 

nerves  of,  47 

veins  of,  46 
Genital  ridge,  44 
Germ  cells,  54 

development  of,  58,  74 
Germ  layers,  cleavage  of,  67 

derivatives  of,  79 

development  of,  74 

formation  of,  67 

in  man,  73 
Germinal  epithelium,  44 
Gestation,     ectopic,     522.     See     Ectopic 

gestation. 
Gingivitis  during  pregnancy,  481 
Glands  of  Bartholin,  22 

vulvovaginal,  22 
Gloves,  use  of,  in  labor,  317 
Glycosuria  during  pregnancy,  486 
Goitre  chuing  i)regnancy,  136 
Gonococcus  in  i)uerperal  infection,  810 
Gonorrheal    infection    complicating   preg- 
nancy, 447 
Graafian  follicle,  55 


INDEX 


847 


H 


Habitual  abortion,  treatment  of,  520 
Hand  presentation  diagnosed  from  breech, 
297 
scrubbing  of,  312 
Head,  after-coming,  714 
delivery  of,  305 
Headache  in  pregnancy,  430 
Heart  during  pregnancy,  134 

disease  during  pregnancy,  459 
Hebosteotomy,  779.     See  Pubiotomy. 
Hegar's  sign  of  pregnancy,  143 
Hematoma  complicating  pregnancy,  444 

of  vulva,  647 
Hemiplegia  during  pregnancy,  459 
Hemophilia  complicating  pregnancy,   470 

puerperium,  470 
Hemoptysis  during  pregnancy,  463 
Hemorrhage,  564 
accidental,  574 
complete,  575 
concealed,  575 
diagnosis  of  577 

differential,  577 
etiology  of,  575 
external,  575 
incomplete,  575 
prognosis  of,  577 
signs  of,  576 
symptoms  of,  576 
treatment  of,  578 
varieties  of,  575 
antepartum,  564 
decidual,  490 
intrapartum,  564 
in  placenta  previa,  566,  567 
postpartum,  564,  585 
diagnosis  of,  587 
etiology  of,  586 
frequency  of,  586 
signs  of,  588 
symptoms  of,  588 
treatment  of,  588 
puerperal,  594 

etiology  of,  594 
treatment  of,  595 
with   a  normally   situated  placenta, 
574  _ 
Hemorrhagic  disease  of  newborn,  413 
Hemorrhoids  complicating  pregnancy,  446 
Herpes  gestationis,  453 
History  of  patient  during  pregnancy,  156, 

158 
Hodge  forceps,  748 
Houston,  valves  of,  29 
Hydatid  of  Morgagni,  41 
Hydatidiform  mole,  491 
etiology  of,  492 
diagnosis  of,  495 
frequency  of,  492 
pathology  of,  492 
prognosis  of,  494 

signs  of,  495  ; 

symptoms  of,  495 
treatment  of,  495  | 


Hydramnios,  500 

diagnosis  of,  502 

etiology  of,  501 

frequency  of,  500 

prognosis  of,  503 

symptoms  of,  502 

treatment  of,  503 
Hydrocephalus,  700 
Hymen,  22 

varieties  of,  22 
Hyperemesis     "gravidarum,     417.        See 

Toxemia  of  pregnancy. 
Hysterectomy  in  puerperal  infection,  833 
Hysteria  diagnosed  from  eclampsia,  432 

in  pregnancy,  454 


Ileus  complicating  pregnancy,  485 
Impetigo      herpetiformis    in    pregnancy, 

453 
Inanition  fever,  389 

Incisions   in   cervix    uteri   to   aid    labor, 
782 
Diihrssen's,  783 
Incomplete  abortion,  508,  516 
Incubators,  362 

substitutes  for,  365 
Indigestion  during  pregnancy,  482 
Induction  of  abortion,  732 
Inertia,  abdominal,  619 

uterine,  610.     See  Uterine  inertia. 
Inevitable  abortion,  508,  515 
Infant  mortality,  836 

statistics  of,  837,  839 
Infection,  puerperal,  809.     See  Puerperal 

infection. 
Infectious    diseases     complicating    preg- 
nancy, 470,  476,  479 
Infundibulopelvic  hgament  of  uterus,  40 
Insanity  during  pregnancy,  456 
puerperium,  457 
of  lactation,"  458 
Interlocking  of  twins,  198,  199 
Internal   rotation    of   fetal   head    during 

delivery,  cause  of,  261 
Interstitial  pregnancy,  523,  525 
Intestinal  auto-intoxication  in  puerperal 
infection,  823 
indigestion  during  pregnancy,  482 
obstruction  during  pregnancy,  485 
Intraligamentous  pregnancy,  525,  549 

rupture  of  Fallopian  tube,  541 
Intra-uterine  amputations,  505 
Inversion  of  uterus.  591 
etiology  of,  592 
prognosis  of,  593 
signs  of,  593 
symptoms  of,  593 
treatment  of,  593 
Ischiocavernosus  muscle,  35 
Ischiococcygeus  muscle,  31,  32 
Ischiorectal  fascia,  33 
fossa,  33 


848 


INDEX 


Jaundice  during  pregnancy,  485 
Justomajor  pelvis,   663.     See  Pelves,  de- 
formed. 
Justominor    pelvis,     653.       See    Pelves, 
deformed. 


IviDXEV.s  during  pregnancy7l34 
dystocia  due  to  lesions  of,  642 

Kilian's  pelvis,  678 

Ivlebs-Loeffler  bacillus  in  puerperal  infec- 
tion. 811 

Ivrause's  method  of  inducing  premature 
labor,  743 

Kyphoscoliotic  pelvis,  688.      See  Pelves, 
deformed . 

Kyphotic    pelvis,    682.     See   Pelves,    de- 
formed. 


L.\Bi.^  majora,  IS 
minora,  19 
lu-ethral,  28 
Labor,  abnormal,  from  anomalies  of  fetus 
in  presentation,  697 
in  forces,  609 
in  passages,  624 
in    absence    or    deformity    of    lower 

extremity,  692 
anesthesia  in,  321 
bed,  preparation  of,  for,  309,  310 
cause  of  onset,  205,  207 
characteristics  of  commencement  of, 

207 
chill  after,  346 

civilization,  relation  of,  to,  205 
in  coxalgic  pelvis,  691 
in  dislocation  of  femur,  691 
in  double  obliquely-  contracted  pelvis 

of  Robert,  663 
draping  of  patient  for  second  stage  of, 

320 
flry,  209 

effect  of  fibroids  on,  633 
exciting  causes  of,  207 
false  pains  in,  207 
first  stage  of,  209 

duration  of,  210 
management  of,  307 
in  fiat,  generally  contracted,  rachitic 

pelvis,  671 
in    generally    contracted,    flat,    non- 
rachitic pelvis,  656 
influence  of  contracted  pelvis  on,  693 
in  justomajor  pelvis,  663 
in  justominor  jjelvis,  654 
in  kyphotic  pelvis,  685 
management  of,  307 
first  stage,  307 
second  stage,  319 
third  stage,  341 


Labor,  mechanism  of,  219.     .See  Mechan- 
ism of  labor, 
in  narrow,  funnel-shaped  pelvis,  657 
normal,  204 
in    obliquely    contracted    pelvis    of 

Xaegele,  662 
in  osteomalacic  pelvis,  675 
pains,  207,  209 
pathological,  609 
physiology-  of,  204 
precipitate,     620.      Sec     Precipitate 

labor, 
preservation   of   pelvic   floor   dm"ing, 

326 
propelling  forces  of,  241,   242 
record  of,  160 
in  scoliotic  pelvis,  688 
second  stage  of,  213 

management  of,  319 
separation  of  placenta  in,  216 
in  simple  flat,  non-rachitic  pelvis,  652 
spinal  anesthesia  in,  323 
in  split  pelvis,  664 
in  spondj-lolisthetic  pelvis,  682 
stages  of,  208 
third  stage  of,  215 

management  of,  341 
in  triplet  pregnancy,  203 
in  twin  pregnane^',  197,  199 
uterine  contractions  in,  241 
uterus,  changes  in,  during,  206,  210, 
213,  215 
Laboratorj'  milk,  408 
Laborde's   method   of   reflex    stimulation 

of  respiration,  360 
Laceration  of  cervix,  579,  723 
diagnosis  of,  724 
etiologj'  of,  723 
symptoms  of,  724 
treatment  of,  724 
of  lower  parturient  canal,  591 
of  permeum,  726 
of  vagina,  725 
of  \Tjlva,  726 
Lactation,  379 

irtsanity  of,  458 
Lactiferous  ducts,  51 
Lactosuria  during  pregnancy,  486 
Legs  and  thighs,  varicosities  of,  complicat- 
ing pregnancv,  445 
Length  of  child  at  birth,  240 
Leucorrhea  during  pregnancy,  153 
Leukemia  complicating  pregnancy,  470 

puerperium,  470 
Leukocytes  during  pregnancy,  132 
Levator  ani  muscle,  31 
Le^Tet  forceps,  748 
Ligament,  triangular,  33 
Lime-water  in  modified  milk,  400 
Liquor  amnii,  abnormal  amount  of,  500 

escape  of,  209,  213 
Lithopedion,  513 

Liver,  affections  of,  during  pregnancy,  485 
during  pregnancy,  1.34 
in  eclampsia,  424 
in  toxemia  of  pregnancy.  421 


INDEX 


849 


Lochia,  372 
alba,  373 
bacteria  in,  374 
rubra,  372 
serosa,  372 
Lordosis,  lumbar,  625 
Lordotic    pelvis,    689.      See    Pelves,    de- 
formed. 
Lower    extremity,    absence    of,    affecting- 
labor,  692 
deformity  of,  affecting  labor,  692 
edema     of,     complicating    preg- 
nancy, 447 
Lungmotor,  360 

Lungs,    affections   of,    during   pregnancy, 
462 


M 


Malaria  during  pregnancy,  476 

puerperium,  476 
Male  and  female  pelvis  contrasted,  228 
MaKormed  uterus,  pregnancy  in,  558 

treatment  of,  562 
Mammary  gland.     See  Breast. 
Mania  during  pregnancy,  457 
Marital  relations  during  pregnancy,  152 
Mauriceau-Smellie-Veit  method,  305 
Measles  complicating  pregnane}'',  477 
Meatus  lu'inarius,  22 
Mechanism  of  labor,  219 

in  breech  presentations,  294 
in  bregma  presentations,  294 
in  brow  presentations,  290 
in  face  presentations,  278 
in  vertex  presentations,  251 
Medical  abortion,  508 
Melancholia  during  pregnancy,  456 
Membranes,  arrangement     of,     in     twin 
pregnancy,  195 
in  triplet  pregnancy,  201 
diseases  of,  491 
Membranous     dysmenorrhea     diagnosed 

from  ectopic  gestation,  546 
Meningocele,  707 
Menopause,  86 
Menstrual  cycle,  80 

periodicitj^,  relation  of,  to  labor,  206 
Menstruation,  80 
cessation  of,  86 

during  pregnancy,  140 
changes  in  body  dm-ing,  85 
during  pregnancy,  126 
effect  of,  on  mother's  milk,  393 
first  appearance  of,  85 
periodicity,  85 
relation  of,  to  ovulation,  86 
type  of,  85 
Mental  condition  during  pregnancy,  153 
Mento-anterior  positions,  birth  of  shoul- 
ders and  body,  285 
descent,  283 
diagnosis,  281 
engagement,  281 
extension,  283 
external  rotation,  285 
54 


Mento-anterior  positions,  flexion,  284 
internal  rotation,  284 
mechanism  of,  281 
molding  of,  281 
restitution  of,  285 
Mentoposterior    positions,    diagnosis    of, 
287 
mechanism  of,  287,  288 
prognosis  of,  289 
treatment  of,  289 
Mesoderm,  changes  in,  76 

derivatives  of,  SO 
Mesodermic  somites,  78 
Metamerism,  78 

Metritis  diagnosed  from  pregnancy,  145 
Milk,  bottles  for,  404 
certified,  397 
cow's,  396 

bacteria  in,  398 

destruction  of,  405 
certified,  397 
compared    with    woman's    milk, 

397 
from  herd,  397 
from  single  cow,  397 
home  modification  of,  398 
modification  of,  397,  398 
fever,  382 
formulae,  400 
laboratory,  408 
modified,  402 

amount  allowed  at  each  feeding, 

402,  404 
composition  of,  398 
diluent  of,  402 
lime-water  in,  400 
preparation  of,  403 
pasteurized  or  raw,  407 
peptonized,  407 
secretion  of,  376 
set,  Sloane  maternity,  402 
woman's,  381,  392 
character  of,  383 
compared  with  cow's  milk,  397 
effect  of  diet  on,  393 

of  menstruation  on,  393 

of  nervous    impressions    on, 

394 
of  pregnancy  on,  393 
quality  of,  391 
quantity  of,  386 
Milk-leg,  820 

in  puerperal  infection,  823 
Miscarriage,  506.     See  Abortion. 

diagnosed  from  ectopic  gestation,  545 
Mixed  feedings,  390 
Molding  of  fetal  head,  240 
Mole,  511 

bloody,  511 

carneous,  511 

fleshy,  511 

hydatidiform,     491.     See     Hydatidi- 

form  mole, 
sanguineous,  511 

vesicular,     491.      See     Hydatidiform 
mole. 


850 


INDEX 


Mons  veneris,  IS 
Monsters,  700 

;inencei)h:ilous,  702 
(loublo,  703 

diajjnosis  of,  704 
nie(;hanisni  of  labor  of,  705 
hydrocephalous,  700 
Montgomery's  tubercles  or  glands,  51 
Morbus  ceruleus,  116 
Morgagni,  columns  of,  29 
crypts  of,  29 
hydatid  of,  41 
Mortality,  infant,  836 

statistics  of,  837,  839 
Mouth,  disorders    of,    during   pregnancy, 

481 
Movable  kidngy  during  pregnancy,  483 
Midler,  duct  of,  47 
Multigravida,  indications  of,  148 
Multiple  pregnancy,  191 
ectopic,  530 
etiology  of,  191 
frequency  of,  191 
triplets,  200 

coiu'se  of  pregnancy  in,  201 
etiology  of,  200 
labor  in,  203 
mortality  in,  203 
placenta;     and     membranes 
in,  201 
twin,  191 

course  of  pregnancy  in  197 
diagnosis  of,  196 
hemorrhage  in,  199 
interlocking  in,  198 
labor  in,  197 
management  of,  199 
mortality  in,  200 
placentae     and     membranes 

in,  195 
presentations  in,  196 
sex  in,  196 
Mummification,  512 


N 


Nabothian  follicles,  39 

Naegele,   obliquely  contracted  pelvis  of, 

659  ' 

Nausea  during  pregnancy,  131,  141,  150 
Nephritis  during  pregnancy,  486 
Nervous  impressions,  effect  of,  on  mother's 
milk,  394 

system  during  pregnancy,  133 
Neuralgia  during  pregnancy,  134,  455 
Neuritis  during  pregnancy,  455 
Nipple,  51 

anticolic,  404 

care  of,  384 

cracked,  385 

depressed,  383 

erection  of,  131 

for  feeding  bottles,  404 
Nitrate  of  silver  for  child's  eyes,  337 
Nitrous  oxide  oxygen  anesthesia,  326 


Nose,    affections    of,    complicating    preg- 
nancy, 481 
Nuchal  hitch,  713,  714 
Nuck,  canal  of,  39 
Nurse,  selection  of,  308 

wet,  394 
Nvu-sing,  act  of,  383 

duration  of,  384 

frec}uency  of,  384 

of  infant,  376 
Nutrition  during  pregnancy,  131 
Nymplue,  19 


Obliquely  contracted  pelvis  of  Naegele, 
659.  See  Pelves,  deformed, 
double,  of  Robert,  662.     See 
Pelves,  deformed. 
Obstetric  fee,  378 
month,  378 
outfit  for  patient,  168 
records,  158,  160,  162 
Obstetrician,    armamentariinn    of,    165 
preparation  of,  312,  320 
visits  of,  during  puerperium,  377 
Obstetrics,  17 

Obturator  internus  muscle',  30 
Occipito-anterior  position,  257 

birth  of  body  and  hips,  265 

of  shoulders,  263 
descent  in,  259 
diagnosis  of,  253 
dilatation  of  cervix  in,  259 
engagement  in,  258 
extension  in,  262 
external  rotation  in,  262 
flexion  in,  259 
internal  rotation  in,  260 
lateral  inclination  in,  259 
mechanism  in,  253,  257,  265 
molding  in,  258 
restitution  in,  262 
Occipitoposterior  positions,  left,  diagnosis 
of,  266 
etiology  of,  266 
frequency  of,  266 
mechanism  of,  266,  268,  276 
prognosis  of,  276 
persistent,  causes  of,  275 
forceps  in,  762 
mechanism  of,  269 
treatment  of,  277,  762 
right,  diagnosis  of,  266 
etiology  of,  266 
frequency  of,  266 
mechanism  of,  266,  268,  275 
prognosis  of,  276 
Oligohydramnios,  503 
Oocytes,  59 
Oogonia,  59 

Oophoritis  in  puerperal  infection,  819 
Ophthalmia  neonatorum,  337,  412 

treatment  of,  413 
Organ  of  Rosemiiller,  44 


INDEX 


851 


Osteomalacic  pelvis,  672.     See  Pelves,  de-    Pelves, 

formed. 
Ovarian  artery,  46  ! 

cyst,  diagnosed  from  pregnancy,  146 

in  puerperal  infection,  823 
pregnancy,  522,  524 
tumor,  complicating  labor,  639 
treatment  of,  640 
pregnancy,  452,  639 
treatment  of,  640 
diagnosed  from  pregnancy,  146 
effect  of,  on  labor,  640 
on  pregnancy,  640 
on  puerperium,  640 
in  puerperal  infection,  823 
Ovaries,  41 

arterial  supply  of,  46 
cortex  of,  43 
Mlum  of,  41 
medulla  of,  43 
■nerve  supply  of,  47 
tunica  albuginea  of,  43 
Oviducts.     See  Fallopian  tubes. 
Ovoid,  fetal,  243 
Ovula  of  Naboth,  39 
Ovulation,  61 

relation  of,  to  menstruation,  86 
Ovum,  54 

changes  in,  in  ectopic  gestation,  538 
fertilization  of,  65 
implantation  of,  97 
maturation  of,  60 
segmentation  of,  67 


Pajot's  maneuver,  763 

Parametritis  in  puerperal  infection,   818 

Paraplegia  during  pregnancy,  459 

Paroophoron,  45 

Parovarium,  44 

Parturient  canal,  219,  230 

injuries  to,  723 
Pasteurization  of  milk,  405 
Pasteurized  milk,  407 
Patient,  preparation  of,  311 
Pelves,  deformed,  648 

contracted,  influence  of,  on  labor, 
693 
on  pregnancy,  692 
prognosis  of,  694 
coxalgic,  690 

diagnosis  of,  691 
influence  of,  on  labor,  691 
double  obliquely  contracted,   of 
Robert,   662 
characteristic, 

663 
diagnosis      of, 

663 
influence  of,  on 
labor,  663 
due  to  anomalies  from  disease  in 
pelvic     articulations, 
677 


deformed,  due  to  anomalies  from 
disease       of      spinal 
column,  678 
of    subjacent    skeleton, 
689 
disease  of  pelvic  bones,  665 
faulty  development,  650 
frequency  of,  649 
generally   contracted,   flat,   non- 
rachitic, 655 
diagnosis      of, 

655 
frequency     of, 

655 
labor  in,  656 
justomajor,  663 

diagnosis  of,  663 
frequency  of,  663 
influence  of,  on  labor,  663 
justominor,  653 

characteristics  of,  653 
diagnosis  of,  654 
frequency  of,  653 
labor  in,  654 
kyphoscoliotic,  688 
diagnosis  of,  687 
influence  of,  on  labor,  688 
kyphotic,  682 

characteristics,  682 
frequency  of,  685 
influence  on  labor,  685 
on  pregnancy,  685 
prognosis,  686 
lordotic,  689 

narrow,  funnel-shaped,  656 
diagnosis  of,  6)7 
etiology  of,  656 
frequency  of,  656 
labor  in,  657 
obliquely  contracted,  of  Naegele, 
659 
characteristics     of, 

659 
diagnosis   of,    661 
etiology   of,    661 
influence      of,     on 

labor,  662 
method  of  delivery 
in,  662 
osteomalacic,  672 

clinical  picture  of,  674 
diagnosis  of,  675 
distortion  in,  673 
etiology  of,  672 
frequency  of,  672 
influence  of,   on  labor,   675 
pathology  of,  673 
treatment  of,  675 
rachitic,  665 

equally  contracted,  671 
etiology  of,  665 
flat,  671 

generally    contracted, 
671 
frequency  of,  665 
pathology  of,  665 


852 


INDEX 


Pelves,  deformed,   iticliitic,   pseudo-ostco- 
malaeie,  ()72 
varieties  of,  668 
scoliotic,  686 

diagnosis  of,  687 
influence   of,   on   labor,   688 
simple  flat,   non-raehitic,   651 

characteristics     of, 
diagnosis  of,  651 
frequenc}'  of,  651 
labor  in,  652 
pregnancy  in,  652 
split,  664 

frequenc}^  of,  664 
influence  of,  on  labor,  664 
spondylolisthetic,  678 
appearance  of,  680 
diagnosis  of,  681 
etiology  of,  680 
frequency  of,  680 
influence  of,   on  labor,   682 
prognosis  of,  682 
transversely       contracted,       of 
Robert,  662 
characteristics     of, 

663 
diagnosis     of,     663 
influence      of,      on 
labor,  663 
varieties  of,  650 
male  and  female,  contrasted,  228 
Pelvic  articulations,  227 

abnormalities  of,  677,  678 
brim,  contraction  of,  625 
fascia,  33 
floor,  31 

preservation  of,  326 
organs.     See  Generative  organs, 
veins,   ligation    and    excision    of,   in 
puerperal  infection,  834 
Pelvimeters,  186 
Pelvimetry,  170,  185  ' 

value  of  external,  176 
Pelvis,  articulations  of,  227 

abnormalities  of,  677,  678 
atrophy  of,  676 
axes  of,  225 
caries  of,  676 
cavity  of,  224 
coxalgic,  690 
deformities    of,    648.       See    Pelves, 

deformed, 
diameters  of,  170,  176 
differentiation  of  male  and  female,  228 
double      obliquely      (contracted,      of 

Robert,  662 
exostoses  on,  675 
false,  221 
fascia  of,  33 
floor  of,  31 
fracture  of,  676 

generally  contracted,  flat,  non-rachi- 
tic,  655 
equally  enlarged,  663 
inclination  of,  225 
inlet  of,  221 


Pelvis,  justomajor,  663 
justominor,  653 
kyphoscoliotic,  688 
ky])lu)tic,  682 
lining  of,  230 
lordotic,  689 

male  and  female,  compared,  228 
measurements     of,     170,     649.     Sec 

Pelvimetry, 
narrow,  funnel-shaped,  656 
necrosis  of,  676 
new  growths  on,  675 
obliquely  contracted,  of  Naegele,  659 
osteomalacic,  672 
outlet  of,  225 
planes  of,  225 
rachitic,  665 

flat,    generally    contracted,    668 
generally  equally  contracted,  671 
pseudo-osteomalacic,  672 
simple  flat,  671 
scoliotic,  686 
split,  664 

spondylolisthetic,  678 
true,  222 
Pendulous  abdomen,  624 

influence  of,  on  pregnancy,  693 
Peptonized  milk,  407 
Perineal  body,  35 
Perineorrhaphy,  727 
Perineum,  lacerated,  726 
etiologv  of,  327 
prophylaxis  of,  328,  727 
treatment  of,  727 
Pernicious  vomiting    of    pregnane}-,    417. 

See  Toxemia  of  pregnancy. 
Perspiration  during  i5ueri)eriiun,  374 
Phlegmasia  alba  dolens,  820 

clinical  pic-ture  of,  821 
etiology  of,  821 
prognosis  of,  822 
Pigmentation  during  pregnancy,  127,  137 

excessive,  452 
Pituitary  extract  in  uterine  inertia,  614 
Placenta,  90,  106 

abnormalities  of,  107 
arrangement  of,  in  triplet  pregnancy, 
201 
in  twin  pregnancy,  195 
bijjartita,  107 

changes  in,  during  latter  part  of  preg- 
nancy, 206 
Crede's  method    of    expressing,    217, 

342 
degenerations  of,  109 
diseases  of,  109 
duplex,  107 

in  ectopic  gestation,  539 
expression  of,  341 

Crede's  method,  217,  342 
fenestrata,  107 
fimctions  of,  106 
inflammation  of,  109 
membranacea,  107 
multiple,  107 
neoplasms  of,  110 


INDEX 


853 


Placenta,  pathology  of,  107 

premature    separation    of,    574.     See 

Accidental  hemorrhage, 
previa,  564 

cause  of  hemorrhage  in,  567 
complete,  54 

diagnosed  from  accidental  hem- 
orrhage, 577 
from  premature  separation, 
577 
diagnosis  of,  568 
etiology  of,  565 
frequency  of,  565 
incomplete,  564 
lateral,  564 
marginal,  564 
partial,  564 
prognosis  of,  569 
symptoms  of,  566 
treatment  of,  570 
varieties  of,  564 
separation  of,  in  normal  labor,  216 
succenturiata,  107 
syphilis  of,  109 
at  term,  106 
triplex,  107 
tuberculosis  of,  110 
varieties  of,  90 
Placentae,  arrangement  of,  in  triplet  preg- 
nancy, 201 
in  twin  pregnancy,  195 
Placentitis,  109 
Pneumonia  complicating  pregnancy,  466 

puerperium,  466 
Polyhydramnios,  500 
Polymastia,  52 
Porro's  Cesarean  section,  788 
Position  of  fetus,  177,  248 

in  face  presentations,  249 
in  vertex  presentations,  249 
Postmortem  Cesarean  section,  800 

delivery,  801 
Postpartum  chill,  346 

hemorrhage,   564,  585.     See  Hemor- 
rhage, postpartum. 
Posture  during  pregnancy,  139 

of  patient    during    second    stage    of 
labor,  319 
Pouch  of  Douglas,  28,  38 

recto-uterine,  28 
Precipitate  labor,  620 

prognosis  of,  621 
treatment  of,  622 
Pregnancy,  abdominal,  523,  525,  549 
air-embolism  complicating,  468 
alimentary  canal,  disorders  of,  during, 

481 
anemia  complicating,  469 
appendicitis  complicating,  483 
appetite  during,  132 
articulations,  changes  in,  during,  139 
ascites  diagnosed  from,  147 
asthma  during,  462 
bathing  during,  151 
bimanual  examination  in,  184 
bladder  during,  136 


Pregnancy,  blood  during,  132 

blood-pressure  during,  133,  135,    155, 

429 
bones,  changes  in,  during,  139 
bowels,  regulation  of,  during,  152 
breasts  during,  153 

changes  in,  127 
symptoms,  141 
carcinoma  of  cervix  complicating,  450 

of  uterus  complicating,  639 
cardiac  disease  during,  459 
cervix  uteri  at  end  of,  231 

changes  in  during,  125,  141,  142 
changes  in  internal  organism  due  to, 
123 

uterus,  due  to,  123,  125,  126 

vagina,  due  to,  126 
cholera  complicating,  478 
chorea  during,  455 
circulation  during,  132 
condylomata  complicating,  449 
constipation  during,  151,  482 
cystocele  complicating,  449 
decidual  diseases  during,  488 
diabetes  during,  486 
diagnosis  of,  145 

differential,  145 
diet  during,  150 
digestion  during,  131 
diseases  complicating,  444,  454 
dress  during,  150 
drink  during,  150 
douches  during,  153 
duration  of,  156 
dyspnea  during,  462 
ear  affections  complicating,  480 
eclampsia  of,  424.     See  Eclampsia, 
ectopic,  522.     See  Ectopic  gestation, 
edema  in,  429 

of  lower  extremities,  447 

of  vulva,  446  ' 
effect  of,  on  mother's  milk,  393 
emphysema  during,  462 
enteroptosis  during,  483 
epilepsy  during,  459 
epistaxis  complicating,  481 
excessive  pigmentation  during,  452 
extra-uterine,  522.     See  Ectopic  ges- 
tation, 
eyes  during,  430,  479 
fibroma  molluscum  in,  454 
fibromyomata  complicating,  451,  632 
gall-bladder  affections  during,  485 
gall-stones  complicating,  485 
gastric  indigestion  during,  482 
gastroptosis  during,  483 
gingivitis  during,  481 
glycosuria  during,  486 
goitre  during,  136 
gonorrheal     infection     complicating, 

447 
headache  during,  430 
heart  during,  134 
Hegar's  sign,  143 

hematoma  of  vulva  complicating,  444 
hemiplegia  during,  459 


854 


INDEX 


Pregnancy,  hemophilia  complicating,  -170 
hemoptj'sis  during,  4G3 
hemorrhoids  complicating,  446 
herpes  in,  453 
hyperemesis  of,  417 
hysteria  in,  454 
ileus  complicating,  485 
impetigo  herpetiformis  in,  453 
indigestion  during,  482 
infectious  diseases  complicating,  470, 

476,  479 
influence  of  contracted  pelvis  on,  692 

of  faulty  presentations  on,  693 

of  fibroids  on,  632 

of  kyphotic  pelvis  on,  685 

of  prolapsed  cord  on,  693 
insanity'  during,  456 
intestinal  indigestion  during,  482 
intraligamentous,  525,  549 
jaundice  during,  485 
kidneys  during,  134,  483 
lactosuria  during,  486 
leucorrhea  during,  153 
leukemia  complicating,  470 
liver  dming,  134,_421,  424,  485 
malaria  during,  476 
in  malformed  uterus,  558 
management  of  normal,  149 
mania  during,  457 
measles  complicating,  477 
melancholia  during,  456 
menstruation  during,  126 
mouth,  disorders  of,  during,  481 
movable  kidney  during,  483 
multiple,    191.     See    Multiple    preg- 
nancy, 
nausea  dming,  131,  150,  430 
nephi-itis  dm-ing,  486 
nervous  diseases  in,  454 

system  in,  133,  430 
neuralgia  in,  134,  455 
neuritis  during,  455 
normal,  management  of,  149 
nose,  affections  of,  compUcating,  481 
nutrition  during,  131 
ovarian  tumors  complicating,  452 
paraplegia  during,  459 
pathologj'  of,  417 
patient,  directions  for,  156 

observation  of,  155 
pernicious  vomiting  of,  417 
physiology  of,  123 
pigmentation  during,  127,  137,  452 
pneumonia  complicating,  466 
postm-e  during,  139 
prolongation  of,  697 
ptj-alism  during,  482 
pulmonary  affections  during,  462 

embolism  complicating,  467 
pruritus  complicating,  453 

^1^lvae  complicating,  448 
pveUtis  complicating,  596.     See  Pye- 
litis, 
record  of  history  and  examination, 

158 
rectmn  in,  136 


Pregnancy,  reflex  cough  of,  463 
respii'ation  during,  133 
salpingitis  compUcating,  451 
scarlet  fever  complicating,  476 
signs  of,  140 
in  simple  flat  pelvis,  652 
skin,  diseases  of,  during,  452,  454 

during,  136 
smallpox  complicating,  477 
special  senses,  disturbances  of,  during, 

479 
spleen  during,  134 
spurious,  146 
striae  during,  137 
symptoms  of,  140 
syphilis  compUcating,  470 
influence  of,  on,  471 
influenced  by,  470 
teeth,  disorders  of,  dm-ing,  481 
threatened  eclampsia  dvu-ing,  424 
thj-roid  gland  dm'ing,  135 
toxemia    of,    417.     See    Toxemia    of 

pregnancy,  and  Eclampsia, 
tuberculosis  complicating,  463 
tubo-abdominal,  550 
twin,  191.     See  Multiple  pregnancy, 
tj-phoid  fever  complicatmg,  478 
urinarj'  tract,  diseases  of,  during,  486, 

487 
urine  during,  134,  429 
vaginal  douches  during,  153 
examination  during,  184 
prolapse  during,  449 
varicosities  complicating,  444,  445 
venereal  warts  complicating,  449 
visual  disturbances  during,  479 
vomiting  during,  131,  417,  430 
vulvovaginal    abscess    complicating, 

448 
weight  during,  131 
Premature  babies,  immediate  care  of,  361 
births,  death  statistics  of,  839 
labor  due  to  fibroids,  633 
induction  of,  736 

by  dilating  cervix  with  elas- 
tic bag,  739 
by   introduction   of   bougie, 

743 
by  puncture  of  membranes, 

744 
by    tamponade    of    vagina, 

743 
indications  for,  736,  737 
methods  of,  738 
prognosis  of,  738 
Presentations  of  fetus,  177,  244 
Presenting  part,  244 
Primigravida,  indications  of,  148 
Prolapse  of  cord,  718 

diagnosis  of,  718 
etiology  of,  718 
frec}uency  of,  718 
influence  of,  on  ]:)regnanc3',  693 
prognosis  of,  719 
treatment  of,'  719 
of  pregnant  uterus,  450 


INDEX 


855 


Protein  in  modified  milk,  398 
in  woman's  milk,  391 
estimation  of,  393 
Pruritus  in  pregnancy,  453 

vulvse,  complicating  pregnancy,  448 
Pseudocyesi^,  146 
Ptyalism  during  pregnancy,  482 
Puberty,  age  of,  85 
Pubiotomy,  779 

contra-indication  to,  781 
indications  for,  781 
objections  to,  781 
prognosis  of,  781 
Pubococcygeus  muscle,  31 
Puborectalis  muscle,  31 
Pudendum,  18 
Puerperal  hemorrhages,  594 
etiology  of,  594 
treatment  of,  595 
infection,  809 

abscess  in,  831 
appendicitis  in,  823 
auto-infection  in,  812 
auto-intoxication  in,  823 
bacillus  aerogenes  capsulatus  in, 
811 
coli  communis  in,  811 
Klebs-Loeflfler,  in,  811 
typhosus  in,  811 
bacteremia  in,  814,  816 
bowels  in,  823 
carriers  of  infection  in,  811 
cellulitis  in,  818 
contagious  diseases,  relation  of, 

to,  813 
diagnosis  of,  822 
douches  in,  828 
etiology  of,  809 
frequency  of,  815 
mortality  of,  816 
pathological  lesions  in,  817 
physical  signs,  817 
prophylaxis,  825 
pyelitis  in,  823 
pyemia  in,  814 
sapremia  in,  814 
septicemia,  814,  816 
site  of  infection,  817 
surgical  treatment,  831 
symptoms  of,  824 
toxemia  in,  814 
treatment  of,  825,  827 
varieties  of,  814,  816 
insanity,  457 
osteophytes,  139 
Puerperium,  369 

anemia  comphcating,  469 
bladder,  care  of,  during,  376 
bowels  during,  375 
catheterization  during,  376 
cervix  uteri,  changes  in,  during,  370 
diet  during,  375 
fibroids,  effect  of,  on,  634 
gall-stones  complicating,  486 
hemophilia  complicating,  470 
insanity  during,  457 


Puerperimn,  leukemia  complicating,  469 
management  of,  369 
pathology  of,  809 
pneumonia  complicating,  466 
pulmonary    embolism    complicating, 

467 
record  of,  162 
Pulmonary  affections  during  pregnancy, 
462 
embolism     complicating    pregnancy, 
467 
puerperium,  467 
Pyelitis  complicating  pregnancy,  596 
clinical  course  of,  598 
diagnosis  of,  600 
etiology  of,  596 
prognosis  of,  602 
treatment  of,  603 
in  puerperal  infection,  823 
Pyemia  in  puerperal  infection,  814 
Pyosalpinx,     ruptured,     diagnosed    from 

ectopic  gestation,  545 
Pyriformis  muscle,  30,  33 


Quickening,  144 


R 


Rachitic   pelvis,    665.     See   Pelves,   de- 
formed. 
Record  of  pregnancy,  158 
Recto-uterine  pouch,  28,  38 
Rectum,  28 

cancer  of,  dystocia  due  to,  642 

columns  of,  29 

during  pregnancy,  136 

sphincters  of,  29 

valves  of,  29 
Reflex  cough  of  pregnancy,  463 
Respiration  during  pregnancy,  133 

methods  of  artificial,  353 
Retinitis,  albuminm-ic,  479 
Retraction  of  foreskin,  411 
Rhomboid  of  Michaelis,  171 
Robert,  contracted  pelvis  of,  662 
Room,  preparation  of,  309 
Round  ligaments  of  uterus,  39 


S 


Sacrococcygeal  articulation,  228 
Sacro-iliac  articulation,  227 
Salivation  during  pregnancy,  141 
Salpingitis   complicating  pregnancy,    451 

in  puerperal  infection,  819 
Salts  in  modified  milk,  398 

in  woman's  milk,  391 
Sanger's  method  of  Cesarean  section,  788 
compared    with   extraperitoneal 
operation,  800 
Sapremia  in  puerperal  infection,  814,  816 


856 


INDEX 


Scales  for  weighing  infants,  387 
Scanzoni's  maneuver,  702 
Scarlet  fever  complicating  pregnancy,  470 
Schultze's  method  of  artificial  respiration, 

355,  350 
Scoliotic  pelvis,  GSO.    See  Pelves,  deformed. 
Scopolamin-morphin  anesthesia,  324 
Scopolamin-narcophin  anesthesia,  324 
Segmentation,  07 
Seizure,  eclainptic,  431 
Semilunar  valves  of  rectum,  29 
Septa  of  cervix  uteri,  045 

of  vagina,  040 
Septicemia  in  puerperal  infection,  814 
Shortening  of  abdominal  cavity,  025 
Shoulders,  delivery  of,  330 
Show,  the,  208 

Silver  nitrate  for  child's  eyes,  337 
Simpson  forceps,  748,  750 
Skene's  glands,  28 

Skin,  diseases  of,  during  pregnancy,  452, 
454 

during  pregnancy,  130 
Sloane  maternity  mifk  set,  402 
Small])ox  complicating  pregnane}^,  477 
Smell  ie  forceps,  748,  749 
Somites,  mesodermic,  78 
Special    senses,    disturbances    of,    during 

pregnancy,  479 
Spermatocytes,  59 
Spermatogonia,  59 
Spermatozoon,  57 

maturation  of,  03 
Spermovium,  05 
Sphincters  of  rectum,  29 
Spinal  anesthesia,  323 
Spleen  during  pregnancj%  134 
Split  pelvis,   004.     See  Deformed  pelves. 
Spondylolisthetic    ))elvis,    078.     See    De- 
formed pelves. 
Spontaneous  evolution,  709 

version,  709 
Spurious  pregnancy,  140 
Staphylococcus    in     puerperal     infection, 

810 
Starvation  temperature,  389 
Stenosis  of  cervix  uteri,  043 

of  vagina,  040 
Sterility  due  to  fibroids,  032 
Sterilization  of  milk,  405 
Stillbirths,  830 

statistics  of,  837,  839 
Stools  of  infants,  409 
Streptococcus  in  puerperal  infection,  810 
Striae  during  pregnancy,  137 
Subinvolution  diagnosed  from  pregnancy, 

145 
Sugar  in  modified  milk,  398 

in  woman's  milk,  391 
Summons,  obstetrical,  307 
Superfecundation,  192  ♦ 

Superfetation,  192 
Sutures  of  fetal  skull,  235 
Sylvester's  method  of  artificial  respiration, 

353 
Symphyseotomy,  770 


Symphyseotomy,  Americ.m  subcutaneous 
method,  777 

Ayer's  method,  777 

French  method,  777 

indications  for,  778 

Italian  method,  777 

open  method,  777 

l)rognosis  of,  778 

result  of,  777 

steps  of  operation,  778 

suprapubic  method,  777 

technic  of,  777 
Synclitism,  259 
Synostosis,  pelvic,  077 

sacrococcygeal,  078 

sacro-iliac,  078 
Syphilis  as  influenced  by  pregnancy,  470 

complicating  pregnancy,  470 

diagnosis  of,  475 

evidence  of,  in  fetus,  472 

influence  of,  on  pregnancy,  47 1 

l)aternal,  470 

of  placenta,  109 

treatment  of,  475 


Tarnier  axis-traction  forceps,  748,  753, 

703 
Teeth  during  pregnancy,  139,  150 

disorders  of,  481 
Temperature,  starvation,  389 
Thermometer,  389 

Thighs,  varicosities  of,  comj)licating  preg- 
nancy, 445 
Threatened  abortion,  508,  515 
Thrombophlebitis  in  puerj)eral   infection, 

819 
Thyroid  gland  during  pregnancy,  135 
Tongue-tie,  411 

Toxemia  of  pregnancy,  417.  See  Eclampsia, 
anesthetics  in,  use  of,  435 
liver  in,  421,  424 
symptoms  of,  429 
treatment  of,  421,  432 
urine  in,  418 
in  puerperal  infection,  814,  817 
Transverse  presentations,  707 
diagnosis  of,  708 
etiology  of,  708 
frequency  of,  708 
mechanism  of,  709 
prognosis  of,  708 
treatment  of,  710 
varieties  of,  707 
Transversus  perinei  muscle,  35 
Traveling  during  pregnancy,  151 
Triangular  ligament,  33 
Triplets,  200 

course  of  pregnancy.  201 
etiology  of,  200 
labor,  203 
membranes  in,  201 
mortality  of,  203 
placentae  in,  201 


INDEX 


857 


Tubal  abortion,  534 
cause  of,  537 
rupture  in,  536 
pregnancy,  523,  524,  525 
Tubercles  of  Montgomery,  128 
Tuberculosis  complicating  pregnancy,  4bd 
efTect  of,  on  pregnancy,  463 
of  placenta,  110 
Tubo-abdominal  pregnancy,  550 
Tubo-ovarian  ligament,  43 

pregnancy,  524,  525  _ 

Tubo-uterine  pregnancy,  o26,  oJt) 
Tucker-McLane  forceps,  748,  752 
Tumors  of  uterus  complicatmg  labor,  b6U 
Twilight  sleep,  324 
Twin  tubal  pregnancy,  530 
Twins,  191.     See  Multiple  pregnancy, 
collision  of,  198,  199 
course  of  pregnancy,  197 
diagnosis  of,  196 
hemorrhage  in,  199 
interlocking  of,  198,  199 
labor  in,  197 

management  of  labor  in,  199 
membranes  in,  195 
placentge  in,  195 
presentation  of,  196 
sex  of,  196 
Typhoid  fever    complicating    pregnancy 
478 


Umbilical  cord,  88,  110 

about  child's  neck.  111,  330 
anomalies  of,  111 
dressing  of,  333 
method  of  hgating,  333 
prolapse  of,   718.     See  Prolapse 
of  cord. 
Undersized  babies,  immediate  care  of,  361 
Urethra,  27 

Urinary  tract,   diseases  of,   during  preg- 
nancy, 486,  487 
Urine  during  pregnancy,  154 
in  eclampsia,  429 
in  toxemia  of  pregnancy,  418 
Uterine  artery,  46 

canal  at  end  of  pregnancy,   231 
distention,  relation  of  labor  to,   206 
inertia,  610 

endangering  maternal   convales- 
cence, 617 
fetal  dangers,  615 
primary,  610 
secondary,  611 
treatment  of.  612 
mucous  membrane,  changes  in,  after 

impregnation,  90 
tumor  in  puerperal  infection,  823 
Uterosacral  hgaments,  40 
Uterovesical  hgaments,  40 

pouch,  38 
Uterus,  36 

arterial  supply  of,  45 
bicornis,  48,  559 


Uter 


us  bipartitus,  560 
broad  ligaments  of,  39 
carcinoma  of,  complicating  labor,  639 
cavity  of,  38 
cervix  of,  36 

changes  in,   during  pregnancy,    123, 
125,  142 
in  ectopic  gestation,  531 
in  first  stage  of  labor,  210 
prior  to  labor,  206 
in  puerperium,  369 
in  second  stage  of  labor,  213 
in  third  stage  of  labor,  215 
coats  of,  38 
cornua  of,  37 
development  of,  47 
didelphys,  48,  559 
external  os,  37 

fibromyoma    of,    complicating    preg- 
nancy, 630,  631,  632 
fundus  of,  37 

height  of,  during  pregnancy,  16o 
incarceration  of  pregnant,  627 
infravaginal  portion,  36 
infundibulopelvic  ligament,  40 
internal  os,  38 
inversion  of,  591 
etiology  of,  592 
prognosis  of,  593 
signs  of,  593 
symptoms  of,  593 
treatment  of,  593 
irregular  contractions  of,  622 
isthmus  of,  36 
lack  of  tone  in,  624 
ligaments  of,  39 
lymphatics  of,  46 
malformations  of,  48 

causing  dystocia,  625 
pregnancy  in,  558 
treatment,  562 
mucous  membrane  of,  39 

relation  of,  to  menstruation, 
81 
muscular  coat,  39 
nerve  supply  of,  47 
peritoneal  pouches  of,  38 
position  of,  in  pregnancy,  126 
prolapse  of,  in  pregnamcy,  450 
retroversion  of,  in  pregnancy,  626 
round  ligaments  of,  39 
rupture  of,  580_ 
complete,  582 

diagnosed  from  premature  sepa- 
ration of  placenta,  577 
etiology  of,  580 
frequency  of,  581 
incomplete,  582 
pathology  of,  582 
prognosis  of,  583 
symptoms  of,  583 
treatment  of,  584 
varieties  of,  582 
sacculation  of,  in  pregnancy,  626,  628 
septus,  50,  559 
serous  coat  of,  38 


858 


INDEX 


Uterus,  supravaginal  portion  of,  36 
tetanic  contraction  of,  623 
tumors   of,    complicating   labor,    630 
unicornis,  50,  558 
uterosacral  ligaments,  40 
utricular  glands,  39 
veins  of,  46 


Vagina,  24 

arterial  supply  of,  45 

atresia  of,  646 

changes  in,  during  px'egnancy,  126 

puerperium,  371 
conditions  of,  causing  dystocia.  646 
development  of,  47 
double.  560 

during  pregnancy,  141,  153 
dystocia  due   to   conditions   of,    646 
at  end  of  pregnancy,  233 
laceration  of,  725 

treatment  of,  726 
lymphatics  of,  46 
septa  in,  646 
stenosis  of,  646 
tumors  in,  647 
veins  of,  46 
Vaginal  Cesarean  section,  783 
disadvantages  of,  786 
indications  of,  785 
technic  of,  784 
douches  during  pregnancy,  153 
examination,   at  beginning  of  labor, 
313 
in  breech  presentations,  296 
during  pregnancy,  184 
frequency  of,  314 
in  L.  M.  A.  position,  281 
in  L.  O.  A.  position,  257 
in  L.  O.  P.  position,  267 
in  R.  M.  A.  position,  281 
in  R.  O.  A.  position,  257 
in  R.  O.  P.  position,  267 
method  of  making,  315 
walls,  prolapse  of,  complicating  preg- 
nancy, 449 
Valves  of  rectum,  29 

Varicosities  of  legs  and  thighs  complicat- 
ing pregnancy,  445 
of  vulva  complicating  pregnancy,  444 
Venereal  warts  comphcating   pregnancy, 

449 
Version,  768 
bipolar,  770 

Braxton  Hicks's  method,  770 
cephalic,  768 


Version,  combined,  770 
external,  769 
indications  for,  768 
internal,  773 
methods  of,  769 
pelvic,  768 
podalic,  768 
spontaneous,  709 
Vesical  calculi,  obstructing  labor,  642 
Vesicular  mole,  491.      See  Hydatidiform 

mole. 
Vertex  presentations,  245 

mechanism  of  labor  in,  251 
positions  in,  249 
Vestibule,  22 

bulbs  of,  22 
Visits  of  friends  during  puerperium,  378 

of  obstetrician,  377 
Visual  disturbances  during  pregnancy,  479 
Vomiting,  during  pregnane}^  131,  141 

pernicious,     417.     See    Toxemia    of 
pregnancy. 
Voorhees's  bag,  616,  739 
Vulva,  18 

changes   in,  during   puerperium,  370 
conditions  of,   causing  dystocia,   646 
during  pregnancy,  153 
edema  of,  647 

complicating  pregnancy.  446 
hematoma    of,     complicating     preg- 
nancy, 444 
lacerations  of,  726 

varicosities    of,     comjjlicating    preg- 
nancy, 444 
Vulvovaginal  glands,  22 

abscess  of,   complicating  pregnancy, 
448 


W 

Weight  chart,  388 

gain  in,  during  pregnancy,  131 
Wet-nurse",  394 
Wharton's  jelly.  111 
Wolffian  body,  44 

duct,  44 

ridge,  44 


Yolk  sac,  88,  90 


ZYGOsrs,  67 


^:?|^^: 


.  itiit.A 


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COLUMBIA   UNIVERSITY 

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DATE  BORROWED 


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